Hormone Pellet (Female) - Fusion Medical Aesthetics

Date*

Name*

First MI Last

Phone*

Birthdate*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact*

Relationship*

Phone Number*

Medical History (check all that apply):

High Blood Pressure
Heart Disease
Asthma
Diabetes
Thyroid Problems
Oesteoporosis
Abnormal Pap
Other

If other, please list:

Please list any prescriptions, over the counter medications, vitamins, and supplements

Have you had any surgeries?*

No
Yes

If yes, then please list year(s) & surgeries below:

Are you allergic to any medications?*

No
Yes

If yes:

Do you use tobacco products?*

Never
Quit
Yes, currently

Type

Number of days per week

Number of years

Please enter a number less than or equal to 100.

Do you drink alcohol?*

No
Yes

If yes, how often?

Other drug use?*

Never
Quit
Yes

General (check all that apply):

Weight change
Fever
Change in appetite
Fatigue
Shaking chills
Night sweats
Weakness

Heart (check all that apply):

Chest pain
Irregular heartbeat
Rapid heartbeat
Swelling in legs

Urinary (check all that apply):

Frequent urination
Leaky bladder

Hormones (check all that apply):

Heat or cold intolerance
Loss of libido
Vaginal dryness
Vaginal laxity
Excessive hunger
Erectile problems

Psychological (check all that apply):

Depression
Anxiety
Drug abuse
Alcohol abuse
Difficulty concentrating
Difficulty sleeping
Loss of interest in activities usually enjoyed

Muscle, Joints, and Bones (check all that apply):

Joint stiffness or pain
Joint swelling
Back pain
Limitation of movement
Muscle pains or cramps

First day of last cycle*

Age of first cycle*

Please enter a number less than or equal to 50.

How often are your cycles? (ex. 28 days, 30 days, etc)*

How long are your cycles?*

Last Pap

Last Mammogram

Sexually Active?*

Yes
No

Current contraception

History of STDs

Lifetime # of partners

Are you in menopause?*

Yes
No
Unsure

Have you had a hysterectomy?*

Yes
No

Do you still have your ovaries?*

Yes
No

Check all that apply:

If "Other Concerns," please indicate:

I understand that all sales are final once payment is made. Fusion does not offer refunds.*

I agree

Signature*

HIPAA INFORMATION AND CONSENT FORM

The Health Insurance Portability and Accountability Act {HIPAA} provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. Amore complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information {PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the US Department of Health and Human Services. www.hhs.gov We have adopted the following policies: 1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately . This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties . 5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor . 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services . 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request. I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.*

I agree

PATIENT RECORD OF DISCLOSURES

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications, or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home. I wish to be contacted in the following manner (check all that apply):

Home Phone Number
Cell Phone Number
Leave a phone message with DETAILED INFORMATION
Leave a phone message with a CALL-BACK NUMBER ONLY
Mail to my home address (as listed in chart)
Mail to my work/office address
Fax
E-mail

Please enter preferred contact information:

With whom may we discuss or disclose information about your care, treatment, or diagnoses? (Please list name and relationship)

MAMMOGRAM WAIVER FOR TESTOSTERONE AND/OR ESTRADIOL PELLET THERAPY

I voluntarily choose to undergo implantation of subcutaneous bio-identical testosterone and/or estradiol pellet therapy, even though I a m not current on my yearly mammogram. I understand that such therapy is controversial and that many doctors believe that estradiol replacement in my case is contraindicated. My Treating Provider has informed me it is possible that taking estradiol could possibly ca use cancer, or stimulate existing breast cancer (including one that has not yet been detected). Accordingly, I am aware that breast cancer or other cancer could develop while on pellet therapy.*

I agree

Signature

For today's appointment I DO NOT have a mammogram for the following reason:

My decision not to have one
Unable to provide the report at this time
My doctor's decision not to have one. (Please provide a note from your treating physician with their rationale as to why they don't want you to have a mammogram.)

I am aware that a current report must be sent by mail or faxed to our office prior to my next HRT appointment. The Treating Provider has discussed the importance and necessity of a mammogram since I receive testosterone and/ or estradiol.*

I agree

Initials

I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was informed of by my Treating Provider. I understand that mammograms are the best single method for detection of early breast cancer. I understand that my refusal to submit to a mammogram test may result in cancer remaining undetected with in my body. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or breast, uterine or cancer issues) that may be sustained by me in connection with my decision to not have a mammogram and undergo testosterone and/or estradiol pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Dr. Gardner, the Treating Provider, and any of their Fusion physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions a rising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone and/or estradiol pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives*

I agree

FEMALE TESTOSTERONE AND/OR ESTRADIOL PELLET INSERTION CONSENT FORM

Sic-identical hormone pellets are concentrated hormones, biologically identical to the hormones you make in your own body prior to menopause . Estrogen and testosterone were made in your ovaries and adrenal gland prior to menopause . Sic-identical hormones have the same effects on your body as your own estrogen and testosterone did when you were younger, without the monthly fluctuations (ups and downs) of menstrual cycles. Sic-identical hormone pellets are made from soy and are FDA monitored but not approved for female hormonal replacement. The pellet method of hormone replacement has been used in Europe and Canada for many years and by select 08/GYNs in the United States. You will have similar risks as you had prior to menopause , from the effects of estrogen and androgens, given as pellets. Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone is category X (will cause birth defects) and cannot be given to pregnant women.*

I have read and understand.

My birth control method is:*

CONSENT FOR TREATMENT: I consent to the insertion of testosterone and/or estradiol pellets in my hip. I have been informed that I may experience any of the complications to this procedure as described below. These side effects are similar to those related to traditional testosterone and/or estrogen replacement. Surgical risks are the same as for any minor medical procedure and are included in the list of overall risks below: Bleeding, bruising, swelling, infection and pain; extrusion of pellets; hyper sexuality (overactive Libido); lack of effect (from lack of absorption) ; breast tenderness and swelling especially in the first three weeks (estrogen pellets only); increase in hair growth on the face, similar to pre-menopausal patterns; water retention (estrogen only); increased growth of estrogen dependent tumors (endometrial cancer, breast cancer); birth defects in babies exposed to testosterone during their gestation; growth of liver tumors , if already present; change in voice (which is reversible) ; clitoral enlargement (which is reversible). The estradiol dosage that I may receive can aggravate fibroids or polyps, if they exist, and can cause bleeding. Testosterone therapy may increase one's hemoglobin and hematocrit, or thicken one's blood. This problem can be diagnosed with a blood test. Thus , a complete blood count (Hemoglobin & Hematocrit) should be done at least annually . This condition can be reversed simply by donating blood periodically. BENEFITS OF TESTOSTERONE PELLETS INCLUDE: Increased libido, energy, and sense of well-being . Increased muscle mass and strength and stamina. Decreased frequency and severity of migraine headaches . Decrease in mood swings, anxiety and irritability. Decreased weight. .Decrease in risk or severity of diabetes . Decreased risk of heart disease . Decreased risk of Alzheimerls and dementia. 1 have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All of my questions have been answered to my satisfaction . I further acknowledge that there may be risks of testosterone and or estrogen therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications , including one or more of those listed above . I accept these risks and benefits and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future pellet insertions. I understand that payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not reimburse me, depending on my coverage . I acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal.*

I understand and agree.

WHAT MIGHT OCCUR AFTER A PELLET INSERTION (FEMALE)

A significant hormonal transition will occur in the first four weeks after the insertion of your hormone pellets. Therefore, certain changes might develop that can be bothersome. FLUID RETENTION: Testosterone stimulates to the muscle grow and retain water which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions. SWELLING OF THE HANDS & FEET: This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, taking cider vinegar capsules daily, (found at most health and food stores) or by taking a mild diuretic, which the office can prescribe . UTERINE SPOTTING/BLEEDING : This may occur in the first few months after an insertion, especially if your progesterone is not taken properly: i.e. missing doses, or not taking a high enough dose. Please notify the office if this occurs. Bleeding is not necessarily an indication of a significant uterine problem. More than likely, the uterus may be releasing tissue that needs to be eliminated. This tissue may have already been present in your uterus prior to getting pellets and is being released in response to the increase in hormones . MOOD SWINGS/IRRITABILITY: These may occur if you were quite deficient in hormones. They will disappear when enough hormones are in your system . FACIAL BREAKOUT: Some pimples may arise if the body is very deficient in testosterone . This lasts a short period of time and can be handled with a good face cleansing routine , astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions. HAIR LOSS: Is rare and usually occurs in patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases. HAIR GROWTH: Testosterone may stimulate some growth of hair on your chin, chest, nipples and/or lower abdomen. This tends to be hereditary. You may also have to shave your legs and arms more often. Dosage adjustment generally reduces or eliminates the problem. Your insertion site has been covered with two layers of bandages. Remove the outer pressure bandage any time after 3 to 4 hours. You may replace it with a bandage to catch any anesthetic that may ooze out. The inner layer is either waterproof foam tape or steri-strips they should not be removed before 2 days. We recommend putting an ice pack on the insertion area a couple of times for about 20 minutes each time over the next 4 to 5 hours. Do not take tub baths or get into a hot tub or swimming pool for 2 days. You may shower but do not scrub the site until the incision is well healed (about 7 days). No major exercises for the incision area for the next 4 days, this includes running, riding a horse,etc. The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days. The insertion may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief, 50 mg. orally every 6 hours. Caution this can cause drowsiness! You may experience bruising, swelling, and/or redness of the insertion site which may last from a few days up to 2 to 3 weeks. You may notice some pinkish or bloody discoloration of the outer bandage. This is normal. If you experience bleeding from the incision, apply firm pressure for 5 minutes. Please call if you have any bleeding (not oozing) or pus coming out of the insertion site that is not relieved by pressure. Remember to go for your post-insertion blood work 6 weeks after the insertion. Most women will need re-insertions of their pellets 4-5 months after their initial insertion. Please call as soon as symptoms that were relieved from the pellets start to return to make an appointment for a re-insertion. The charge for the second visit will be only for the insertion and not a consultation unless you would like to discuss treatment and additional hormonal health matters. DO NOT GO TO YOUR DERMATOLOGIST FOR ANY ACNE ISSUES! TESTOSTERONE PELLETS AND ACNE ARE NOT TREATED WITH ANTIBIOTICS. Dr. Gardner and her staff have all of your acne treatment options available here at FUSION including medical skin care lines, microdermabrasion and chemical peels. These cost effective treatments will help clear your acne as well as prevent fine lines and wrinkles.*

I have read, understand, and agree.