Please read this form entirely. It contains information to assist you in making a decision to have a specific therapy. Initial each paragraph if you understand it. If you do not understand it, do not initial it and each paragraph will be discussed with you separately. There are risks and complications that may result from this therapy, they are rare, but do exist and you must be aware of them.
Thyroid hormone regulates the body’s metabolic rate, heart and digestive function, muscle control, brain development and bone maintenance. The expectation of treatment is improvement in symptoms of hormone deficiency and possibly decreased health risks.
_____ Possible side effects of ThRT include increased pulse rate, palpitations, racing heart, weakness, leg cramps, sweating, shaking, anxiety, insomnia, decreased appetite, weight loss, fever, hair loss, nausea, vomiting, excessive sweating, and heat intolerance.
_____ Rare complications include decreased bone density, chest pain, shortness of breath, abnormal heart rhythms, impaired fertility, and abnormal menstrual cycles.
_____ I understand that there are studies which show a suppressed TSH level is associated with bone loss or over-stimulation of the heart. I understand there are other studies that do not show this risk.
_____ The above listed risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization and/or extended outpatient therapy to permit adequate treatment.
_____ I will conform and comply with the recommended dosing of ThRT. If recommended, I will obtain baseline and periodic lab tests to assure proper monitoring of my ThRT.
_____ I understand that medicine is not an exact science and that no guarantees are offered regarding my expected results. I am aware that it is possible that this treatment will not work for me.
I have read the foregoing information, it has been explained, and I understand it. All of my questions have been answered. By executing this form, I am indicating that I have no questions whatsoever and I give my full informed consent to have ThRT prescribed.
Patient / Legal Guardian Signature / Date:
Medical Assistant/Nurse/Physician / Date:
