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Patient Consent for Medical Services

This Consent for Medical Services (“CONSENT”) specifies the terms and conditions under which, you, the undersigned patient (“PATIENT”) may secure the availability of medical services offered by (“PRACTICE”):

Pure Health & Wellness 6065 N First St, Fresno, CA 93710

This consent applies to the PRACTICE, its agents, employees and physician(s). PATIENT and the PRACTICE hereby enter into this agreement for provision of medical services specified herein (SERVICES). Wherefore, in exchange for consideration, the receipt and sufficiency of which the parties hereby acknowledge the PATIENT and PRACTICE agree as follows:

1. The PATIENT acknowledges and agrees that this agreement has been entered into before the PRACTICE has provided the SERVICES specified herein to the PATIENT.
2. The PATIENT acknowledges and agrees that this agreement has not been entered into at a time when the PATIENT is facing an emergency or an urgent health care situation.
3. The PATIENT acknowledges reading and receiving a copy of the Notice of Privacy Practices, and by signing this agreement, the PATIENT authorizes the PRACTICE and its representatives to use and share PATIENT health information as described in the Notices of Privacy Practices.
4. The PATIENT agrees to let PRACTICE, its agents, employees, and physician(s) provide medical care services. The SERVICES provided to the PATIENT may include:
   1. Evaluation of patient medical history and lifestyle behaviors
   2. Physical examination
   3. Blood, urine, fecal, and/or saliva tests
   4. Diagnostic testing, bioelectrical and/or imaging tests
   5. Medical recommendations and management regarding my health issues and disease prevention
      1. Nutrition
      2. Nutritional supplementation and/or replacement
      3. Physical activity, functional performance, and exercise
      4. Lifestyle, environment, and behavior
      5. Stress response management
      6. Hormone replacement therapy
   6. Medication prescription management for those medications prescribed by the PRACTICE
   7. Procedures may include but are not limited to
      1. Injections
      2. Intravenous infusion therapy
      3. Aesthetic procedures

PATIENT agrees that PRACTICE has not made any claims or statements about results or cures.

Duration of Consent: PATIENT acknowledges the right to revoke this consent at any time except to the extent PRACTICE has already taken action in reliance on it. If PATIENT does not revoke it, this Consent will continue indefinitely. By signing this agreement, the PATIENT acknowledges that PATIENT has read and fully understands the information contained in this agreement. PATIENT agrees that everything in this Consent applies to current and future health care services provided by PRACTICE

Informed Consent for Human Growth Hormone Replacement

• I understand that prescription Human Growth Hormone (HGH) has been approved by the Food and Drug Administration (FDA) for the treatment of Adult Growth Hormone Deficiency (AGHD).  This condition is determined from medical history, physical findings and laboratory tests.
• I understand that the laboratory tests to measure IGF-1 or Somatomedin-C might not meet the criteria to establish adult growth hormone deficiency.
• I understand that Human Growth Hormone replacement therapy may result in improvements in my health associated with declining growth hormone levels, which may include one or more of the following: improved muscle mass, strength, exercise capacity, bone density, immune function, skin thickness, wound healing, memory, lung function, and heart function.
• I understand that my healthcare provider cannot guarantee any health benefits or that there will be no harm from the use of Human Growth Hormone.

• I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medical community as new, controversial, and unnecessary by the Food and Drug Administration.
• I understand that while the application of Human Growth Hormone has been utilized in adults for more than twelve years its long-term effects are undetermined.
• I understand that HGH is contraindicated when there is any evidence of neoplastic (cancer) activity, proliferative diabetic retinopathy, pulmonary fibrosis, or recent coronary angioplasty.  Intracranial lesions must be inactive and anti-tumor therapy complete prior to institution of therapy.  HGH should be discontinued if there is evidence of tumor growth.  It should not be initiated to treat patients with acute critical illness due to complications following open heart or abdominal surgery, multiple accidental traumas, or to patients having acute respiratory failure.  Caution is required when HGH is administered to patients with diabetes mellitus, as insulin dosage may need to be adjusted.
• While the New England Journal of Medicine, October 1999, concluded, “There is no evidence that HGH replacement therapy affects the risk of cancer or cardiovascular disease,” I understand that questions have been raised about HGH as a cause of cancer, since it is an anabolic hormone and makes things grow.

• I understand that side effects may occur with the use of HGH.
• Possible side effects include but are not limited to: edema (swelling) of the hands and ankles, parethesias (numbness and tingling in the hands), arthralgias (joint aching), slight bruising at the injection site, and glucose intolerance, at least initially, where blood sugar is higher for a given amount of sugar or equivalent consumed.  Excess doses may result in fluid retention in the hands and feet.  Continued fluid retention could lead to headaches and/or joint pain, and possibly carpal tunnel syndrome, increased blood pressure or insulin resistance.

• I am totally and completely satisfied with my understanding of the reasonable alternatives to human growth hormone replacement, which include:
• Leaving the hormone levels as they are and doing nothing.  Risks may include but are not limited to: experiencing symptoms of growth hormone deficiency and an increased risk for aging-related diseases or dysfunction resulting from declining growth hormone levels.  This alternative may result in the need to treat diseases or dysfunction associated with declining growth hormone levels as they appear clinically.
• Treating the symptoms of declining growth hormone levels as they develop with non-hormonal therapies.  Risks may include, but are not limited to:  increased risk for aging-related diseases resulting from declining hormone levels

• I agree to comply with the proposed treatment and therapy as prescribed, including the fact that I may be responsible for injecting the human growth hormone prescribed to me, and consent to periodic monitoring, when requested, which may include: Laboratory monitoring of blood or urine chemistries and hormone levels, Physical examinations, and/or Regular screening evaluations.
• I agree to notify you 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 you.  I agree to comply with the recommendations regarding the continuation or discontinuation of these preparations.
• In the future I will receive recommendations in advance from you before stopping any of the prescribed therapeutic regimens or taking any additional preparations that are not suggested or prescribed by you.
• I also understand that the use of “social substances” such as tobacco, “street drugs,” and alcohol and other types of otherwise non-described “social substances” may affect my therapy in a significantly adverse manner.
• I certify that I am under the care of a physician(s) for any and all other medical conditions.

• I understand that the prescribing physician is not engaged in any personal research and has no economic interests unrelated to my immediate care or treatment that may affect the physician’s choice of treatment or medical judgment
• 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 human growth hormone replacement therapy.  I believe I have adequate knowledge upon which to base an informed consent.
• I do now 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.

Informed Consent for Testosterone Replacement Therapy

• Expected benefits include control of symptoms associated with declining testosterone levels.
• Possible benefits of this therapy may help prevent, reduce or control physical diseases and dysfunction associated with declining testosterone levels, through hormonal replacement.
• I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medical community as new, controversial, and unnecessary by the Food and Drug Administration.
• I understand that my healthcare provider cannot guarantee any health benefits or that there will be no harm from the use of testosterone replacement therapy.

• 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 testosterones administered by injection or pellet implants.
• Currently there are no testosterone supplement products approved by the FDA for usage by women.
• 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.
• A prescription testosterone, administered by injection, pellet implants, transdermal cream or patch.
• Risks of testosterone replacement include but are not limited to: stimulation of benign and malignant prostate tumor. Testosterone replacement is contraindicated in patients with known prostate cancer.
• The FDA requires manufacturers to add a caution to the warning label that testosterone could increase the risk of heart attack and blood clots in veins and could increase the risk of deep vein thrombosis and pulmonary embolism; and that the drugs are only approved to treat low testosterone levels caused by injury or disease.
• Side effects of testosterone replacement may include but are not limited to: an abnormal increase in the number of red blood cells, determined by periodic measuring of your blood. While not a common occurrence and generally posing no health risk, it can be corrected by donating blood or with a therapeutic phlebotomy. Male pattern baldness, gynecomastia (breast enlargement), diminished sperm production (infertility) and a reduction in the size of the testicles (testicular atrophy) may develop in men. Testosterone replacement may reduce insulin requirements in insulin- dependent diabetics. Older male patients may be at a slightly increased risk for the development of prostate enlargement when replacing testosterone. The concurrent use of testosterone with corticosteroids may enhance edema (fluid retention) formation. Edema may be a complication with testosterone replacement in patients with pre-existing cardiac, renal, or hepatic disease. Sleep apnea may by worsened by testosterone replacement. It has not been established whether testosterone replacement therapy will increase the risk for prostate cancer.
• The most common immediate side effects (occurring in approximately no more than 6% of users) include, but are not limited to: acne, application site reaction (rash, itching, or irritation), headache, hypertension (high blood pressure), abnormal liver function tests, and non-cancerous prostate disorder. Other side effects may include greasy hair and skin, a strong body odor, and aggressiveness.
• Testosterone replacement therapy in females is considered an off-label application by the FDA.
• Relative contraindications of testosterone replacement in pre- and postmenopausal women include androgenic alopecia, acne, hirsutism, hyperlipidemia and liver dysfunction. Absolute contraindications are the presence or increased risk of breast cancer, endometrial cancer, veno-thrombotic episodes and manifest cardiovascular disease
• Discontinuation of testosterone replacement therapy may be recommended for a period of 1-2 weeks postoperatively.
• Transdermal testosterone cream can be transmitted by direct contact. We have advised you of the potential harm of transference to others and how to avoid transference to others.

• Leaving the testosterone levels as they are and doing nothing. Risks may include but are not limited to: experiencing symptoms of testosterone deficiency, and increased risk for aging-related diseases or dysfunction resulting from declining testosterone levels. This alternative may result in the need to treat diseases or dysfunction associated with declining testosterone levels as they appear clinically.
• Treating the symptoms of declining testosterone levels as they develop with non-hormonal therapies. Risks may include, but are not limited to: increased risk for aging-related diseases resulting from declining testosterone levels

• I agree to comply with the proposed treatment and therapy as prescribed, including the fact that I may be responsible for injecting, taking by mouth, applying to my skin, or administrating the testosterone(s) that may be prescribed to me, and consent to periodic monitoring, when requested, which may include
  • Laboratory monitoring of blood, saliva or urine chemistries and testosterone levels
  • Physical examinations
  • Regular screening evaluations
• I agree to notify you 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 you. I agree to comply with the recommendations regarding the continuation or discontinuation of these preparations.
• In the future, I will receive recommendations in advance from you before stopping any prescribed therapeutic regimens or taking additional preparations that are not recommended by you.
• I certify that I am under the care of a physician(s) for any and all other medical conditions.

• I understand that the prescribing practitioner is not engaged in any personal research and has no economic interests unrelated to my immediate care or treatment that may affect the physician’s choice of treatment or medical judgment

Control Substance Auto-refill Consent

1. I understand that TMC will not call and/or email to notify me or Pure Health & Wellness that my medication is being refilled.
2. I understand that this form is a legal replacement in regards to receiving a call to notify me that my prescription is due to be filled and will be shipped to me without confirmation.
3. I understand that it is my responsibility to immediately report any change in regards to my shipping address.
4. I understand that myself will be held responsible for notifying Tailor Made Compounding in the event my controlled substance package(s) are lost/stolen. I or will inquire about the next steps for contacting UPS and filing a police report, and I fully understand if I do not take these next steps that I may not be eligible for any medication replacements.
5. I understand that myself will be held responsible for any added expenses of lost or stolen packages.
6. I understand that I will be responsible for notifying TMC if I have a pause and/or discontinuation of medication.
7. I understand that it is myself or Pure Heatlh & Wellness responsibility for notifying TMC if my dosing or quantity prescribed has changed and any previous prescription’s refills will need to be canceled.
8. I understand that if I do not notify TMC before a prescription has left their facility, I will still be held responsible for the payment of this prescription.