Hormone Pellet (Female) - Fusion Medical Aesthetics

Date*

Name*

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Birthdate*

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Relationship*

Medical History (Check any that apply):

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

If other, please list:

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

Have you had any surgeries?*

Yes
No

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
Yes, currently
Quit

Type

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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
Fatigue
Shaking Chills
Night Sweats
Weakness
Change in Appetite

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
Excessive hunger
Loss of libido
Vaginal dryness
Vaginal laxity
Erectile problems

Psychological (check all that apply):

Depression
Anxiety
Drug abuse
Difficulty concentrating
Alcohol abuse
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

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

I agree

Signature*

FEMALE HEALTH HISTORY

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:

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 April14, 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:

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.
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.
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.
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.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
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

Signature*

Date*

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
Written Communication

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Leave a message with DETAILED INFORMATION
Leave a message with a CALL-BACK NUMBER ONLY

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Mail to my home address (as listed in chart)
Mail to my work/office address

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Fax
E-mail me at

Fax / Email Address

Please enter preferred contact information:

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

Patient Signature*

Todays Date*

Your Name*

First Last

Birth Date*

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use of disclosure ot and requests for, PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses of disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided on this form, if completed properly, will constitute an adequate record. Uses and disclosures may be permitted without prior consent in an emergency.

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

Patient Name*

First Last

Patient Signature*

Todays Date*

Provider Name

First Last

Provider Signature

Todays Date

FEMALE TESTOSTERONE AND/OR ESTRADIOL PELLET INSERTION CONSENT FORM

Name*

First Middle Last

Todays Date*

Bio-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. Bio-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.

Bio-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 OB/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:*

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 hairgrowth 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 o f Alzheimer’s and dementia.

I 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.

Name*

First Last

Signature*

Todays Date*

No Show/Late Cancelation Policy

Dear Patient:

This consent acknowledges that you accept responsibility to pay a late fee of $50 for any cancelation that occurs less than 24 hours (1 business day) before your appointment is scheduled or any appointment that you fail to show up for.

Any appointment that you are unable to keep we kindly require that you give our designated advance notice from you so another patient can use your original appointment time.

Patient Signature*

Today Date*

Lab Values:

As you embark on your journey with me to get your hormones back on track, you will notice that your lab values (levels) will appear “elevated” or “high” when compared against the ranges provided by the lab company. They are NOT elevated, but instead they actually reflect that you are on hormone replacement therapy. You may see values between 100-400ng/dl for your new Testosterone number. These are normal lab values for women on Testosterone therapy.

If you feel that your Testosterone level may feel “too much” for you then there is a reversing agent available by prescription called Spironolactone. This medication is an anti-testosterone that I can use to bind the free testosterone in your body. Too much testosterone may feel like aggression, hair loss, voice changes or hair loss. Oftentimes, hair loss can be reduced with 40mg of Zinc that you take daily. I also recommend Head and Shoulders shampoo for hair loss or Sunday Riley scalp detox serum (sundayriley.com) to break down the waxy build up on your scalp that can also be a result of testosterone treatment, pollution, and product build up. Use the code WELCOME10 for 10% off your first order.

New data was released in June of 2021 that showed that when a woman starts estrogen (estradiol) at the very beginning of menopause, she reduces her risk of major health problems including heart disease, breast cancer, stroke, and reduced risk of Alzheimer’s dementia. We are honored to partner with you on your journey to be the best version of yourself as you enter this phase of your life.

Thank you for being a patient, and I am glad you are here.

Warmest Regards Always,

Dr. Lisa Gardner-Phillips

Patient Signature*

Today Date*

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 the muscles to 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.

UTERINE SPOTTING/BLEEDING: If you are receiving Estrogen and you have a uterus you MUST take oral progesterone daily and not miss any doses. If you miss even one dose you may begin bleeding. If bleeding occurs, double your dosage of progesterone for a minimum of 14 days or continue until the bleeding ends. 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 on our line of medical grade skincare.

HAIR LOSS: Is rare and usually occurs in patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. We offer medical grade supplements that can support the hair follicle and help prevent hair loss.

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. A dosage adjustment generally reduces or eliminates the problem. We also offer Laser Hair Removal as a service as well.

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 3-4 months after their initial insertion.

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 your acne treatment options available here at FUSION, including medical skin care lines. These cost-effective treatments will help clear your acne as well as prevent fine lines and wrinkles.

I have read, understand, and agree.