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Patient Information:

First Name: *

Legal name not nickname. Prescriptions must match Legal name

Last Name: *

Date of birth: *

Please confirm year is not current year

Driver’s License: *

Some state require Driver License for all Prescriptions

Address

Street Address: *

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Sex assigned at birth:

HIPAA Acknowledgement and Consent

The undersigned understands that the Medical Center is required by law to maintain privacy of protected health information and has provided the patient/patient’s representative with a notice of its privacy practices regarding health information.

Please check all that apply: *

Office may leave messages on answering machine

Office may call cell phone

Office may call patient at work

Office may leave message with spouse and/or significant other.

Office should only speak with patient.

Information may be given to other family members. List:

Authorized individuals

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SMS Marketing

Talon Wellness uses SMS Messaging to keep patients updated on treatment options:

SMS Marketing *

You agree to receive automated transactional messages about your treatment plan. Text and data rates may apply. Reply STOP to end service.

I do NOT agree to automated messages.

The following are all patient consent forms

None commit you to any purchase or promise delivery of any product

PATIENT TELEHEALTH CONSENT FORM

I consent to treatment involving the use of electronic communications to enable health care providers at different locations to share my individual patient medical information for diagnosis, therapy, follow-up, and/or education purposes. I consent to forwarding my information to a third party as needed to receive telemedicine services, and I understand that existing confidentiality protections apply. I acknowledge that while telemedicine can be used to provide improved access to medical care, as with any medical procedure, there are potential risks and no results can be guaranteed or assured. These risks include, but are not limited to: technical problems with the information transmission; equipment failures that could result in lost information or delays in treatment. I understand that I have a right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

Patient Authorization for Delivery of Medications

I hereby authorize the clinic's staff on duty to act on my behalf to accept medication delivery from the clinic's dispensing nurse practitioner and deliver my medications and refill to me as prescribed by the practitioner.

I understand that delivery of such medications can be picked up at the clinic or mailed to my provided address on a weekly basis (or as often as ordered by the practitioner). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

No Guarantee of Services

We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign-up process and practitioner's examination.

At the practitioner's discretion only, you will be provided with medications and/or services during your program at Talon Wellness.

INFORMED CONSENT FOR HORMONE REPLACEMENT THERAPY

I, the undersigned, authorize and give my Informed Consent to Talon Wellness for the administration of hormone replacement therapy (“HRT”).

Because of the rapidly changing research regarding the safety and efficacy of HRT for anything other than birth control, it is important that you have information about the risks and benefits of HRT before you undergo the therapy you have discussed with your Talon Wellness healthcare provider.

Expected Benefits of Hormone Replacement Therapy

Expected benefits include control of symptoms associated with declining hormone levels.
Possible benefits of this therapy may help prevent, reduce or control physical diseases and dysfunction associated with declining hormone levels, through hormonal replacement.
When hormone levels are brought back to within the “normal range” for your age, there is significant evidence that your overall health benefits.
I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medial community as new, controversial, and unnecessary by the Food and Drug Administration (“FDA”).
I understand that my healthcare provider cannot guarantee any health benefits or that there will be no harm from the use of hormone replacement therapy.

Risks and Side Effects of Hormone Replacement Therapy:

HRT is approved by the FDA only for prescribed deficiencies. Using it for other symptoms or problems is considered "off-label" use, and the liability is on the patient, not the provider. Some of the following risks/adverse reactions are derived from the official FDA labeling requirements for these drugs, for therapeutic drug levels in the blood stream. My healthcare provider may prescribe these medications at dosages designed to achieve physiologic levels of hormones in my blood stream or urine generally associated with those of a 20-35 year-old person and would be within the “normal” or “average” blood concentrations of that age group.

General Risks:

I understand that the general risks of this proposed therapy may include, but are not limited to, bruising, soreness or pain, and possible infection for hormones administered by injection.
I understand that there are risks (both known and unknown) to any medical procedure, treatment and therapy, and that it is not possible to guarantee or give assurance of a successful result. I acknowledge and accept these known and unknown general risks.

Testosterone:

Risks of testosterone replacement include but are not limited to stimulation of benign and malignant prostate tumors. Accordingly, testosterone replacement is contraindicated in patients with known prostate cancer
Side effects of testosterone replacement may include but are not limited to: An increase in the red blood cells; Male pattern baldness; Gynecomastia (breast enlargement); Diminished sperm production and a reduction in the size of the testicles may develop in men; Reduction of insulin requirements in insulin-dependent diabetics; Prostate enlargement; Acne; Application site reaction; Headaches; Hypertension; and Abnormal liver function tests.

Estrogen:

Risks associated with estrogen replacement include, but are not limited to: Heart attacks; Blood clot formation; Gallstones; Increased risk of uterine cancer (if progesterone is not administered with concurrently); and Fibroid tumors.
Estrogen replacement is not recommended in women with a history of the following conditions: Breast or uterine cancer; Phlebitis and blood clots; Gall bladder disease; Uterine fibroma; and Liver disease.
Side effects of estrogen replacement may include but are not limited to: Increased body fat; Fluid retention; Uterine Bleeding; Depression; Headaches; Impaired glucose tolerance; and Aggravation of migraines.

Progesterone:

Risks associated with progesterone replacement include, but are not limited to: Progestins may cancel the protective effect of estradiol and promote constriction of the coronary arteries; and Progestins may cause birth defects, da e to nerve cells, blood clots and breast cancer.
Side effects of progesterone replacement may include but are not limited to: Nipple or breast tenderness; Drowsiness; Fluid retention; Slight dizziness; Anxiety; Depression; Acne; Hot flashes; Appetite increases; and Weight gain.

Alternatives to Hormone Replacement Therapy:

I understand the reasonable alternatives to hormone replacement therapy, which include:

Leaving the hormone levels as they are and doing nothing; and
Treating the symptoms of declining hormone levels as they develop with non-hormonal therapies.

Patient’s Obligation While Receiving Hormone Replacement Therapy:

I agree to comply with the proposed treatment and therapy as prescribed;
I agree to periodic monitoring, when requested, which may include: Laboratory monitoring of blood or urine chemistries and hormone levels; physical examinations; and regular screening evaluations;
I agree to notify my provider regarding all signs or symptoms of possible reactions to my therapy;
I agree to comply with all other healthy lifestyle activities that have been individually recommended for me;
I have completely disclosed my medical history, including prescription and non-prescription medications that I am currently taking or plan to take during my treatment, as well as any other over-the-counter medications, recreational drugs or social substances, herbs, extracts, and other dietary supplements to my provider. I agree to comply with the recommendations regarding the continuation of these preparations;
In the future I will receive recommendations in advance from my provider before stopping any prescribed therapeutic regimens or taking additional preparations that are not recommended by my provider; and
I certify that I am under the care of a physician(s) for any and all other medical conditions.

I certify that I have been given the opportunity to ask any and all questions I have concerning the proposed treatment, and I received all requested information and all questions were answered. I fully understand that I have the right to not consent to hormone replacement therapy. I believe I have adequate knowledge upon which to base an informed consent.

I attest to reading and fully understanding this form and the contents and clinical meanings of such and discussing these procedures with my healthcare provider and consent to this treatment, and hereby affix my signature to this authorization for this proposed long-term treatment. I have been given a copy of this consent form, and I understand fully any and all of the possibly represented implications and meanings of its writing and expectations.

Patient Name: *

Patient Signature: *

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Date: *