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.
Testosterone has many beneficial effects, including increasing bone strength and density, increasing red blood cell production, driving sexual function and libido, providing a cardioprotective effect and increasing muscle strength. The expectation of treatment is improvement in symptoms of hormone deficiency and possibly decreased health risks.
_____ Possible side effects include breast swelling or tenderness, acne, increased body hair, excess red blood cell production, sleep apnea, aggressive or hostile mood, excess libido.
_____ Rare complications may include blood clots, stroke, tendon rupture.
_____ I understand that TRT does not increase the risk for prostate cancer, however TRT will stimulate an existing prostate cancer.
_____ I understand that the bulk of studies show TRT will reduce the risk of heart disease but there are conflicting studies which show an increased risk of heart disease with TRT.
_____ 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 TRT. If recommended, I will obtain baseline and periodic lab tests to assure proper monitoring of my TRT.
_____ 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 TRT prescribed.
Patient / Legal Guardian Signature / Date:
Medical Assistant/Nurse/Physician / Date:
