BHRT Female Consent

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Patient Information

First Name*

Last Name*

Email*

Date of Birth*

Address*

City*

State*

Zip Code*

Emergency Contact Name*

Emergency Contact Number*

Occupation*

Preferred Language*

Race*

Driver’s License number*

Drivers License State*

Patient Vitals

Biological Sex*

Height (inches)*

Weight (lbs)*

Who is your Primary Care Provider?*

Blood Pressure (Systolic)*

Blood Pressure (Diastolic)*

Last Bloodwork/Labs*

Last Physical Exam*

Health History

Please list all medications, supplements, or current hormone dosages & frequencies of what you are currently taking*

Are you currently on or have you taken in the past hormone replacement?*

Yes

Please Specify Type of Hormone Replacement

Personal Health History - Please check all that apply*

Family History - Does anyone in your family (living or deceased) have the following*

Do you Smoke?*

Yes

Do you Drink Alcohol?*

Yes

Do you use any Illicit Drugs?*

Yes

Are you sexually active?*

Yes

Smoking Type and Frequency

Alcohol Type & Frequency

Drug Type & Frequency

Do You Desire More Children*

Yes

Are you pregnant or trying to get pregnant?*

Yes

Last Pap smear & any abnormal results*

If not trying for a pregnancy list contraceptive or barrier method you are using*

Number of pregnancies and live births*

Please enter a number from 0 to 10.

Last Mammogram, any abnormal results?*

Symptoms - Are you noticing:*

Please list any allergies*

Disclosures

HIPAA Consent*

I have read, understand, and consent to the above.

Your right to privacy in this medical practice is paramount and we will never disclose any of your personal information without your express consent, unless required to do so by law. This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. Please read it carefully. The Physician will acquire private information about their patients. This is confidential and will not be discussed outside the office, except that the Physician may discuss patients with other healthcare professionals in terms that do not allow identification of the individual. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment. Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts, or contact by alternative means. Additionally, we may be required to disclose your health information in the following circumstances: In the event of an emergency; if required by law; if there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care; if ordered by the courts, government authorities, public health, law enforcement, coroners, or funeral directors; in the event of organ donations, research, military activity, or for national security.

Consent to treat*

I have read, understand, and consent to the above.

I request the use of BHRT and supplements to treat my condition(s). I understand that as part of the program, I will be given an orientation to the program with supporting materials and I will be instructed on how to either administer the prescribed medication or supplement myself or have it administered for me in the office by medical staff. I understand there is no guarantee for the effectiveness of these medications or supplements. I agree that I am and will be under the care of another medical provider for all other conditions. The provider can work in conjunction with, but cannot replace, my regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine. I understand the provider can only prescribe medications and or supplements necessary for this treatment and all other health matters should be through my regular physician(s). Prior to my treatment, I have fully disclosed any medical conditions, diseases, allergies, and home medications and supplements and any contraindications have been fully discussed with me. If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with this procedure. Nutritional and Exercise counseling: the patient was strongly encouraged to adopt a low-glycemic, balanced whole food diet, restricting processed foods, trans fats, and simple sugars. A regular high-intensity exercise program along with a healthy diet is a key factor in optimizing the health benefits of testosterone therapy. Reviewed the importance of lifestyle factors including adequate sleep (6-8 hours per night) and stress reduction in improving energy, mood, and libido.
The patient understands the risks and benefits as discussed.
Safety of any of these hormones during pregnancy cannot be guaranteed. Notify your Provider if you are pregnant, suspect that you are pregnant, or are planning to become pregnant during this therapy. Estrogen Therapy: Bio-identical estrogens are available in various forms including oral capsules, troches, patches, pellets and topical creams. Side effects may include breast tenderness, bleeding, or fluid retention which can occur from too much estrogen or increased sensitivity. Do not take estrogen if you have breast cancer. Verve Health LLC uses Estradiol for treatment. Progesterone Therapy: Bio-identical progesterone is available in various forms including oral capsules, troches, vaginal suppositories, and topical creams. Progesterone therapy may be sedating, so it is recommended to coordinate dosing with sleep cycle. Adverse reactions are associated with non-bioidentical Progesterone and may include bloating, breakthrough bleeding, missed menstrual cycles, breast swelling and tenderness, fluid retention, weight gain, sedation, and depression. Verve Health LLC uses micronized P4 Progesterone. Testosterone Therapy: Bio-identical testosterone therapy is available in various forms including topical creams, pellets and injections. Side effects can include acne, increased libido, or hirsutism (facial hair growth). Synthetic hormones such as Progestins, and bioidentical hormones have different effects on the body. Bioidentical hormones can be used and metabolized as our body was designed to do, thus potentially minimizing side effects. Compounded bioidentical hormone dosages can be fine tuned to your specific needs. Many European studies suggest that bioidentical hormones are safer than synthetic hormones. However, that doesn’t mean that bioidentical hormones are perfect. Although the use of bio-identical hormone replacement therapy has been shown in many studies to be safer than synthetic hormone replacement therapy, the risk of side effects is still possible. In fact, there are physicians who do not agree with the use of bioidentical hormones.
Baseline hormone levels are ordered on or before your initial visit. You will then be given an individualized prescription of BHRT based on your symptoms and test results. Symptom resolution is not immediate. It can take anywhere from 3-9 months until patients feel like they have the perfect fit. There are many different preparations of BHRT (topical creams, injectables, and pills). Some individuals respond to one form better than another. Laboratory blood tests are measured 6-8 weeks after initiating BHRT. When stable, hormone levels are then monitored every 6-12 months depending on the situation.
Patient's bodies and lifestyles change and so do their hormonal needs. It is recommended you continue to have all of your yearly preventative screening tests such as pap smears (as frequently as indicated), mammograms, DEXA Scans (as indicated), and a pelvic ultrasound (as indicated), and colonoscopy (as indicated), etc. Patient consents they are under a primary provider?s care and are receiving physicals and any preventative care needed. Patient verbalizes understanding and requests and consents to the administration of Bioidentical Hormone Replacement Therapy (BHRT) and oral supplements and authorizes that these will be prescribed by the healthcare provider(s) at Verve Health LLC.
Patient acknowledges and understands the following:
There are no guarantees or assurances made with respect to the benefit of hormone replacement therapy prescribed for me, and I understand that BHRT is not specifically approved by the FDA for preventative medicine and my request for BHRT is off-label, unless a medical diagnosis can be made. There are certain potential risks involved in hormone replacement therapy. I agree to report to the healthcare provider any adverse reaction or problems that might be related to my hormone therapy.They will be in charge of administering the hormones and supplements prescribed and will conform and comply with the recommended doses and methods of administration.Abuse of hormones or poly-pharmacy is not tolerated and care will be terminated immediately if this occurs. The medical literature indicates that there may be health benefits to the use of BHRT and its long-term effects are undetermined and Verve Health LLC cannot guarantee any results or that there will be no harm. The potential health risks and benefits of using BHRT have been explained to me to my satisfaction.

Consent to Telehealth*

I have read, understand, and consent to the above.

"Telehealth Consent
Telehealth involves the use of electronic communications to enable health care providers to provide patient care through the means of live two-way audio and/or video. The purpose of this form is to obtain your consent to participate in a Telehealth consultation for various medical conditions/illnesses. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and/or video and Output data from medical devices and sound and video files. During the telehealth consultation: details of your medical history, examinations and tests will be discussed using interactive video and/or audio, a virtual examination may take place, other medical professional such as a medical assistant may be present during the visit to assist the provider, and photographs may be take during the service if needed and you consent. In an emergency, it is the responsibility of the Telehealth provider to direct the patient to emergency medical services, such as an emergency room. The Telehealth provider may also discuss and advise with the patient's local provider (if applicable). The Telehealth provider's responsibility will end upon the termination of the Telehealth connection.
Confidentiality
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the Telehealth consultation.
Possible Risks
As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. The session may be discontinued by the patient and/or the provider if the video conference connection is not adequate for the situation.
Your Rights
You may withhold or withdraw consent to the Telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Patient Consent"

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