Hormone Replacement Therapy (HRT) Member Information

(Telehealth or Brick-and-Mortar)

Date: {{current_date}}

Patient Information

• **Patient Name: {{patient_first_name}} {{patient_last_name}} {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Date of Birth: {{patient_birthdate}}** {{patient_input}}

Purpose of HRT

Your medical provider has prescribed hormone replacement therapy (HRT) for the purpose of reducing symptoms that may be due to low levels of testosterone, DHEA, estradiol, progesterone, thyroid and Vitamin D3 such as weight gain, loss of muscle mass, lethargy, concentration issues, short-term memory loss and decreased libido. While there are no guarantees of results from HRT, many members have experienced improvement in these symptoms. Even if your hormone levels are within normal range for your age, hormonal therapy may be prescribed to address a specific functional deficiency.

While taking hormones, you should immediately inform the treating medical professional(s) of any symptoms or side effects, which may include:

Potential Side Effects and Risks

Testosterone-Related Side Effects:

• **Prostate-Related Effects:** If you already have enlargement of your prostate gland, your signs and symptoms can get worse while using Testosterone. This can include: increased urination at night, trouble starting your urine stream, having to pass urine many times during the day, having an urge to go to the bathroom right away, having a urine accident, being unable to pass urine or weak urine flow.

• **Prostate Cancer Risk:** Possible increased risk of prostate cancer. Your healthcare provider should check PSA levels or any other prostate problems before you start therapy and while you are on testosterone.

• **Fertility Effects:** In large doses Testosterone may lower your sperm count. While this effect may be temporary, men who are planning to have children are recommended to produce sperm samples for freezing as a precaution before beginning testosterone therapy because it can affect ability to conceive.

• **Physical Changes:** Enlarged or painful breasts; nipple tenderness

• **Common Adverse Events:** The most common adverse events are: skin redness or irritation (if applied topically), increased red blood cell count, headache, diarrhea, vomiting, and increase in blood level of Prostate Specific Antigen (a test used to screen for prostate cancer).

General Side Effects:

Hair loss: This side effect is usually temporary as your body adjusts to the medication. Stop the Medication and call your provider if you experience any serious side effects including but not limited to: Allergic reaction (rash, itching and swelling especially in face or tongue, severe dizziness, trouble breathing, increased sweating, sensitivity to heat, mental/mood changes, fatigue, diarrhea, shaking/tremor, headache, shortness of breath, chest pain, fast/pounding/irregular heartbeat, swelling in hands/ankles/feet or seizures.

Testosterone Pellet Information

Testosterone may be administered via subdermal pellet implants. These pellets are a natural soy-derived bioidentical testosterone inserted under the skin of the lateral buttocks to achieve a steady and consistent delivery of hormone into the bloodstream. Pellet extrusion (coming out) has been known to occur on rare occasions. In addition, there is a slight chance of a wound infection, as with any type of surgical procedure. Wound infection can be easily treated with an antibiotic, or very rarely, incision and drainage. Pellets dissolve naturally within 4 to 12 months after implantation, and should be considered irretrievable once inserted. However, in extraordinary circumstances, pellets may be removed via a minor outpatient surgical procedure. Pellets may be added if needed to achieve desired results/blood levels.

Secondary Exposure Warning

Cases of secondary exposure of testosterone have been reported in children, other adults in close proximity who are not taking testosterone, and pets. Children, pregnant women, and pets should avoid contact with unwashed or unclothed application sites in members using testosterone creams.

Patient Acknowledgment

I have read and understood all of the above information. I understand the risks and benefits of the proposed treatment, and have asked and received answers to my questions.

Signatures

Patient Signature: {{patient_input}} Date: {{patient_input}}

Provider Signature: {{patient_input}} Date: {{patient_input}}

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., CO., Primary Medical of IN, P.C.

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