Testosterone Replacement Therapy Disclosure and Consent Form

• I understand that testosterone replacement therapy protocols have not been standardized and there are no guarantees with respect to success of such treatments
• I hereby consent to the administration of testosterone for the purpose of restoring my levels to a healthy range. I understand that testosterone replacement is best administered by intramuscular injection.
• I understand that there are potential risks such as pain, swelling, redness at the injection site, brief cough right after injection, increased acne, increased body hair, breast swelling/sensitivity, low sperm count, testicular shrinkage, increased red blood cell count, elevated PSA level.
• I have been informed that while testosterone replacement therapy has not been shown to increase risk of prostate cancer, heart attacks, blood clots or strokes, it may not provide protection against these disorders, and they still may occur due to other factors.
• I understand that licensed healthcare professionals at this clinic are treating my hormone deficiency, and any neglect to my health needs may result in discharge from this clinic.
• I understand that testosterone replacement therapy is administered under closed medical supervision and failure to follow our guidelines may result in negative responses, complications and possible health risks.

• I have been informed that while testosterone replacement alone or in combination with estrogen and progesterone replacement has not been shown to increase risk of blood clots, heart attacks, strokes, breast and uterine cancer, it may not provide protection against these disorders, and they still may occur due to other factors.
• I understand that it is contraindicated to be pregnant while on testosterone replacement therapy. If there is any chance that I could be pregnant, I will consent to blood or urine pregnancy test prior to beginning of treatment.
• I understand that while on testosterone replacement therapy, I may get increased facial or body hair, increased acne, breast tenderness, clitoral enlargement, fluid retention, deepening of my voice, irritability. I also understand that these side effects are reversible with dose adjustments.