This is intended to serve as a confirmation of informed consent for medical treatment.
Patient Informed Consent
I voluntarily request that Radiate Healthy LLC
treat my medical condition.
I have informed my provider of any known allergies, my medical conditions, medications, social/family history.
I understand that I have the following responsibilities:
Medical history: I will tell my provider my complete medical history, including: allergies, medications, medical/surgical/social/family history.
My provider may ask to review, with my permission, my medical history (medications, recent lab results, pertinent imaging results).
I will tell my provider any updated health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
My provider can discuss my treatment plan with any co-treating pharmacist and/or healthcare provider
I will always tell other providers about all medications I am taking.
I am aware:
Testosterone replacement therapy includes use of products such as injectable Depo-Testosterone and Testosterone Cypionate as well as topical products
including Transdermal Testosterone Patches and Transdermal Testosterone Gel.
Testosterone replacement is approved for cases of primary hypogonadism as well as hypogonadotropic hypogonadism. Other uses may be
considered off label. The safety and efficacy of testosterone supplementation for off label use is not established.
Contraindications for use of hormone replacement therapies.
You should not use testosterone if you have any of the following:
Known hypersensitivity to the drug
Breast cancer
Prostate cancer
Serious Heart, Liver, Kidney Disease
Women who are or may become pregnant
Potential risks associated with testosterone use include, but are not limited to:
Application site or injection site reactions
Injury to Muscle, Blood Vessel, or Nerves caused by injection
Blood Clots which could lead to Heart Attack, Pulmonary Embolism, or Stroke
Polycythemia
Exacerbation of Congestive Heart Failure or Edema
Enlargement of the Prostate
Worsening of Prostate Cancer
Worsening of Sleep Apnea
Depression or Anxiety
Gynecomastia (male breast enlargement)
Elevated PSA
Elevated Cholesterol
Moodiness, Irritability, Aggression
Urinary Retention
Male Pattern Hair Loss
Acne
Elevated Calcium Levels
Hepatitis (prolonged high-dose use)
Hepatocellular Cancer (prolonged high-dose use)
Virilization of Women or Children unintentionally exposed to transdermal products.
Laboratory tests required prior to initiating testosterone treatment, and during regular follow-up and management during the course of testosterone treatment, include but are not limited to:
Total Testosterone,
Free Testosterone,
Estradiol, Sensitive, LC/MS,
SHBG,
DHEA-S,
PSA,
LSH,
FH,
CBC,
Hemoglobin & Hematocrit,
CMP,
Lipid Panel,
TSH,
Free T3,
Free T4,
Reverse T3,
Ferritin,
Testosterone-containing medications are a controlled substance as designated by the DEA and should be stored in a safe and secure place to prevent unauthorized access and use. Keeping this medication in a lock box, locked cabinet, or safe is recommended. It is against federal regulation to sell, share, or distribute this prescription to anyone for whom it has not been prescribed.
Failure to comply with required follow-up appointments and monitoring, including follow-up lab work, will result in termination of therapy.
I have reviewed the risks and side effects associated with use of Testosterone containing products. I have had the opportunity to ask and have questions answered. I consent to initiating/continuing treatment with Testosterone containing products. I agree to notify the office immediately if I suspect any adverse reaction or side effects from treatment.
HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- Radiate Healthy LLC reserves the right to change the privacy policy as allowed by law.
- Radiate Healthy LLC has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- Radiate Healthy LLC may condition receipt of treatment upon execution of this consent.
By signing this consent you agree that Radiate Healthy LLC can:
Leave a message on your answering machine at home or on your cell phone.
Contact you by phone, text message, or e-mail to confirm appointments or discuss treatment plans. .
Privacy Practices
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our Notice before signing this Consent. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on you prior Consent.
The patient understands that:
Protected health information may be disclosed or used for treatment, payment or health care operations.
All other disclosures by the practice will require specific authorization by you unless required by law.
The Practice has a Notice of Privacy Practices and that the patient can review this Notice and receive a copy.
The patient has the right to restrict the uses of their information used for treatment, payment, or operations, but the Practice does not have to agree to those restrictions.
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 provider’s examination. At the provider’s discretion only, you will be provided medications and/or services during your program at Radiate Healthy LLC.
RadiateHealthy LLC requires you to have a regular consultation with our provider and laboratory work as needed.
No Refund Policy
RadiateHealthy LLC reserves the right to have NO RETURN and NO REFUND policy.
I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for medical treatment.
