Intake form

 

  New Patient Intake

General Information

Participant: Please write legibly as this information is used to complete your patient chart.

Family Physician and/or Primary Health Care Provider:

For Women only:

Women only(continued)Please check Yes or No:

Please sign below, indicating that you have answered the questions accurately and to the best of your ability.

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BHRT and Pregnancy Disclaimer, Warning, and Patient Agreement (Premenopausal Women)

I understand that testosterone replacement therapy is not to be used by female patients who are pregnant or trying to become pregnant. I have been counseled on the potential risks of using testosterone replacement therapy during pregnancy, particularly the fact that testosterone usage in pregnant women has sometimes been shown to partially masculinize the external genitalia of a developing female fetus (potentially resulting in an enlarged clitoris, ambiguous genitalia, etc). Furthermore, I understand that I should not be taking estrogen or progesterone supplementation while pregnant or trying to become pregnant.

Pregnancy is a very intricate and delicate hormonal process and any exogenous hormones taken during pregnancy may have a detrimental effect on that process. With these risks in mind, I agree to use a consistent and reliable form of contraception while on hormone replacement therapy to reduce the chances of pregnancy. Additionally, I agree to immediately notify Optimal Medicine, if at any time that I am taking BHRT: I decide to attempt to become pregnant, decide to discontinue contraception, or discover that I am pregnant so that they can quickly and safely discontinue my hormone replacement therapy.

I acknowledge understanding of the above-mentioned disclaimer/agreement and agree to release Optimal Medicine staff and healthcare practitioners from any claims of liability for any potential adverse outcomes that may result from my failure to comply with this agreement.

Initial below:

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BHRT Informed Consent to Treat

The Nature of the Treatment

 

I hereby give my consent to evaluation and treatment by Optimal Medicine’s staff and healthcare practitioners of the following specified condition(s):

 

Women: menopause or menopausal symptoms (including potential repletion of estrogen/estradiol, progesterone, DHEA, testosterone)

 

Men: andropause or associated symptoms (including potential repletion of testosterone and DHEA, potential lowering of estrogen/estradiol levels)

 

Men/Women: other hormone imbalances (*please specify in other) - Thyroid abnormalities, Growth hormone abnormalities including decreased or suboptimal IGF -1, decreased or suboptimal Vitamin D-3 levels.

 

Men/Women: other (*please specify in other) – Nutritional deficiencies (vitamins, minerals, amino acids, etc)

– may include IV infusion supplementation, Overweight/Obesity (may include medically supervised weight loss with appetite suppressants – phentermine -, injectables (Lipo-C), etc.

Alternative Treatment Methods and Their General Nature

 

The reasonable alternatives to this treatment have been explained to me and they include:

  1. Leaving the hormone levels as they
  2. Treating age related diseases as they
  3. Using pharmaceutical agents that are not bioidentical in nature (synthetics)

I understand the foregoing alternatives and am choosing to consent to the treatment plan prepared for me by Optimal Medicine to address the condition(s) indicated above.

 

The General Nature and Extent of Treatment- Related Risks

 

 

Safety of Hormone Replacement

 

Although, in my physician’s opinion, the majority of data points toward safety, there remains controversy regarding the correlation between the use of bioidentical hormone therapy and cancer. Recent data demonstrates that natural progesterone and estriol/estradiol may be protective against breast cancer.

 

I understand that careful surveillance and close monitoring are requirements of all patients to minimize any possible risk. I understand that Optimal Medicine will monitor my hormone levels and various other laboratory values as they pertain to my treatment goals. However, I also understand that an integral part of health maintenance is obtaining and remaining up to date with age appropriate screening tests aimed at early detection of life-threatening diseases.

My Obligations and Representations

 

Any questions I have regarding this treatment have been answered to my satisfaction. I understand that I will be responsible for administering the hormones prescribed to me. I will comply with the recommended dose and methods of administration. I also agree to participate in the initial and subsequent hormone testing, as required to safely monitor and treat my hormone levels.

 

I certify that I am under the regular care of another physician (Primary Care Physician, OBGYN, Urologist, etc.) for all other medical conditions. I will consult my physician(s) for any other medical services I may require. I understand that this is a specialized practice. I also understand that I will continue under the care of my other physician(s) for any on-going medical condition as well as for any medical consultation that I may need.

 

Being aware of all aforementioned facts and notices in this document, and after weighing potential risks vs potential benefits, I elect to commence the aforesaid treatment at Optimal Medicine’s staff or healthcare providers, and assume full liability for any adverse effects that may result from the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the therapy, except as that claim pertains to grossly negligent administration of the therapy.

 

I fully understand the nature and purpose of portions of the aforementioned treatment may be considered experimental because of the lack of adequate scientific evidence or peer-reviewed publications supporting the underlying premise of bioidentical hormone replacement therapy and that such therapy might even be considered by some medical professionals to be medically unnecessary because it is not aimed at treating a particular disease.

 

I understand that I may suspend or terminate treatment at any time and hereby agree to immediately notify the physician of any desire to suspend or terminate this treatment so that such suspension or termination may be done safely.

 

Consent

 

I hereby authorize my physician to evaluate and treat the conditions I specified on the above pages (this is a

4-page document). I understand my physician may be assisted by other health professionals, as necessary, and agree to their participation in my care as it relates to the evaluation and treatment of the conditions this Consent to Treat covers. I certify that I am 18 years of age or older, am competent to sign this Consent to Treat, and have done so of my own free will.

 

 

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Patient Authorization for Delivery of Medications

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 physician’s examination.

At the physician’s discretion only, you will be provided medications and/or services during your program at Optimal Medicine.

OAM requires you to have an annual consultation with our provider and annual lab work done. Lab work every 6 months is preferred but not required. Additional lab work can be requested by the provider at any time.

No Refund Policy

 

*Optimal Medicine reserves the right to have NO RETURN and NO REFUND policy.

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FINANCIAL POLICY

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Photo Identification Requirement:

Please upload a photo copy image of your Driver's License or State ID (front and back).

Patient-Physician Contract

We are now in a new era of Health Care Reform - intended to help patients. Sadly, these reforms do not include any “Lawsuit Reforms” that would dramatically reduce costs for patients and also promote a better environment for patients and their physicians. In a recent nationwide poll* 83% of the nation’s electorate wanted Congress to address the medical malpractice system as part of the Health Care Reform plan. We wish Congress had taken action implementing reforms that both doctors and patients could support. And the majority of patients agree. Congress missed the opportunity. Because of that we have taken action with the single goal of enhancing the relationship between patients and the physician.

 

We take great pride in our reputation for providing the highest levels of quality medical care to our patients. However, we realize there are times when some patients will not be satisfied with the outcomes of their treatments. We also recognize that in these instances, a patient has every right to pursue legal action if he/she feels we have been negligent in some way. We respect every patient’s right to do so.

 

While some healthcare legal claims are justified, there are also frivolous legal claims filed in our country—claims that are driving up insurance rates and impacting court decisions for the patients who truly deserve compensation. We believe that an agreement early in the treatment process regarding the use of properly credentialed experts will help expedite resolution of concerns.

 

OUR COMMITMENT TO YOU

We commit to using only properly credentialed expert medical witness(es) in any legal situation, who follow the code of ethics of our national specialty society. These steps ensure that expert medical witnesses we use have passed examinations, demonstrated expertise in their field and adhere to a solid code of ethics.

We demonstrate this commitment to you with our signature on this form. WHAT WE ARE ASKING YOU TO DO

We are asking you or any representative to commit to this process also, by using only properly credentialed physician(s) as expert medical witness(es) if you are dissatisfied with your medical care and decide on legal action.

 

We hope, and believe, you will never have to consider this again. But if you do, we will honor this commitment to you.

 

* Poll conducted by Clarus Research Group (www.ClarusRG.com), a nonpartisan survey research firm based in Washington, DC

AGREEMENT AS TO RESOLUTION OF CONCERNS

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Authorization for Release of Medical Records

*This document MUST be signed by the patient in order to receive copies of their complete medical records including but not limited to test results and treatment plan for themselves.

The health care provider(s) authorized to release this information are: (please print)

B.I authorize the following health information to be disclosed:

TO

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