Annual Testosterone Consent

Testosterone therapy may be prescribed to address symptoms related to low testosterone levels, including fatigue, mood changes, decreased libido, and other clinical concerns. This treatment involves the administration of testosterone via injection, topical application, or oral ingestion, depending on your provider's recommendation. Testosterone replacement is approved for cases of primary hypogonadism as well as hypogonadotropic hypogonadism. Other uses may be considered off label. The safety and efficacy of testosterone supplementation for off label use is not established.

 

Contraindications

You should NOT use testosterone if you have any of the following:

• Known hypersensitivity to the drug, Breast cancer, Prostate cancer, Serious Heart, Liver, or Kidney Disease, and Women who are or may become pregnant.

 

Potential Risks

Include, but are not limited to:

• Application site or injection site reactions, Injury to Muscle, Blood Vessel, or Nerves caused by injection, Blood Clots which could lead to Heart Attack, Pulmonary Embolism, or Stroke, Polycythemia, Exacerbation of Congestive Heart Failure or Edema, Enlargement of the Prostate, Worsening of Prostate Cancer, Worsening of Sleep Apnea, Depression or Anxiety, Gynecomastia (male breast enlargement), Elevated PSA, Elevated Cholesterol, Moodiness, Irritability, Aggression, Urinary Retention, Male Pattern Hair Loss, Acne, Elevated Calcium Levels, Hepatitis (prolonged high-dose use), Hepatocellular Cancer (prolonged high-dose use), and Virilization of Women or Children unintentionally exposed to transdermal products.

Medical Monitoring & Lab Requirements

Laboratory tests required prior to initiating testosterone treatment, and during regular follow-up and management during the course of testosterone treatment, include, but are not limited to:

• Testosterone level, PSA, Blood Count (CBC), Blood Sugar, Cholesterol, Thyroid, and Calcium tests.
• Ongoing lab work is required every 3 months to monitor your body's response to testosterone therapy and ensure safe, effective treatment.
• Failure to comply with required follow-up appointments and monitoring, including follow-up lab work, will result in termination of therapy. You agree to follow all provider instructions regarding dosage, frequency, and follow-up appointments.

Consent & Acknowledgment

• I acknowledge that lab testing may be subject to insurance coverage limitations. It's my responsibility to verify coverage and understand any out-of-pocket costs. Missed labs or appointments may result in cancellation or rescheduling fees and refill delays.
• Testosterone containing medications are a controlled substance as designated by the DEA and should be stored in a safe and secure place to prevent unauthorized access and use. Keeping this medication in a lock box, locked cabinet, or safe is recommended. It is against federal regulation to sell, share, or distribute this prescription to anyone for whom it has not been prescribed.
• I have reviewed the risks and side effects of associated with use of Testosterone containing products. I have had the opportunity to ask and have questions
• I consent to initiating/continuing treatment with Testosterone containing products. I agree to notify the office immediately if I suspect any adverse reaction or side effects from treatment.