Hormone Therapy General Consent

(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}} {{patient_input}}
• **DOB:** {{patient_input}}

Consent for Hormone Replacement Therapy

I request and consent to the administration of hormone replacement therapy (HRT), which may consist of Testosterone, Estradiol and other bio-identical hormones prescribed by my medical provider.

Financial Agreement

I agree to pay for all hormones and any insertion fees at the time of administration. I understand there are NO REFUNDS once therapy has begun. I understand that some pharmaceuticals used in my therapy may be sold or dispensed in multiple dose packages and that I may not be permitted to take possession of any unused doses if I discontinue therapy for any reason. If I receive a prescription for any pharmaceuticals, I understand that early refills may not be available in the event of loss or theft.

Patient Acknowledgment and Certification

I have read and understood all of the above consent conditions. I acknowledge that I have received additional more specific information pertinent to my treatment so that I fully understand the risks and benefits of the proposed treatment, and that it is my responsibility to read and understand this information and to ask questions about anything I do not understand fully.

I certify that I have not had any other treatments related to Hormone Therapy from any other facility or physician in the last 3 months, and if so, I have notified my Medical Provider and this includes any over the counter treatments.

Signatures

Print Name: {{patient_first_name}} {{patient_last_name}} {{patient_input}}

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

Witness / Provider Signature: {{patient_input}} Date: {{current_date}}

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

2025.04.22

Form Complete