Off-Label 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}}
  • **Date of Birth: {{patient_birthdate}}** {{patient_input}}

Hormone Replacement Therapy Information

It is important that you understand the risks and benefits associated with Hormone Replacement Therapy (HRT) before beginning or continuing treatment. HRT is not a new area of medicine, however the treatment modalities may involve innovative therapies and there are no guarantees with respect to the treatment prescribed. You should also be aware of alternatives to HRT, including not receiving HRT treatment, leaving hormone levels as they are, and treating age-related diseases and symptoms as they appear. It is important that you consider the information we provide and discuss the information carefully with your provider. Be sure that you are doing what is right for you. If you are unsure, then you should refuse and/or discontinue treatment.

Patient Consent

"This is my consent to begin treatment for Hormone Replacement Therapy."

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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Signature Certificate
Off-Label Consent
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Timestamp Audit
2026-03-03 09:12:15 EDTOff-Label Consent Uploaded by EnnuLife Patient Docs - docs-admin-ennulife@ennulife.com IP 24.238.5.27
2026-03-09 12:25:16 EDTDocument viewed by EnnuLife Patient Docs - docs-admin-ennulife@ennulife.com IP 24.238.5.27