I ACKNOWLEDGE AND ACCEPT (Consent, HIPAA and Medical History forms)
By checking the box, you ACKNOWLEDGE AND ACCEPT that you have read and agree to all of the following:
Treatments and conditions as described in the Consent for Evaluation and Treatment.
Treatments and conditions as described throughout the Medical History form.
Treatments and conditions as described in the HIPPA form.
Consent for Evaluation and Treatment
I voluntarily authorize Mehta & Mehta Medical Consultants Inc. DBA eMD Men’s Clinic and its Physicians, Nurse Practitioners, Physician Assistants, Medical Assistants, and associated personnel to evaluate and treat my health concerns. I understand that my treatment may consist of a balanced diet, a regular exercise program, nutritional supplements, injections, instructions in behavior modification techniques and may involve the use of prescription drugs.
1. I have been informed that I may be treated with therapies including, but not limited to the following:
Nutritional supplementation and Diet counseling
Weight loss Protocols
2. Risk of proposed treatments: I understand that any medical treatment may involve risks as well as the proposed benefits. I have been well informed of any such risks of treatment including death, the risks of refusal of treatment, and the treatment alternatives have been explained to my understanding.
3. No Guarantees: I understand that much of my healing success is dependent upon my commitment to following the treatment plans outlined for me by the doctor and or provider. Even following the program designed specifically for me may not result in the desired outcome. I also understand that my condition may be life long and may require changes in eating habits and permanent changes in behavior to be treated successfully.
4. Information developed as part of evaluation/treatment is confidential but may be released to those parties as required by law such as:
In medical emergencies involving danger to self or to others;
Upon presentation, or reasonable suspicion of abandonment/neglect or physical/sexual abuse of a child or elder; a court order; upon receipt of a properly executed consent form; and where otherwise legally required
5. Treatment is individualized to specific needs and may result in emotional and physical discomfort through the healing processes.
Nothing should be construed here-in that there is a perfect remedy or treatment for those disease states considered terminal or incurable.
WARNING: If you have any questions regarding the risks or hazards of the proposed treatment or any questions concerning the proposed treatment or other possible treatments, ask the physician now before signing this consent form.
Patient’s consent: I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been encouraged and have been given all the time I need to read and understand this form.
Telemedicine Health Care
DBA eMD Men’s Clinic provides telemedicine health care specializing in Program’s Designed For Your Specific Health Needs:
Testosterone Replacement Therapy
Lifestyle exercise programs
No longer do you have to be in the state or country to have an appointment, or maybe you just don’t feel well enough to get out of bed or dressed to leave home. If work is too pressing to leave or you have a meeting you can’t miss, make an appointment and eMD Men’s Clinic can schedule a consultation via Zoom.
I, the patient, have read the release of liability and understand that my seeking of additional health care should/can be cleared by my primary care physician. I am seeking medical assistance from eMD Men’s Clinic for additional/alternative/traditional/integrative medical care. If my medical needs are not met either by any recommendation or if I feel I need additional care, I will take responsibility for contacting my primary care physician for additional medical services. I will make my primary care physician aware of my past/current and future intentions for medical treatments, traditional and alternative. I will request the clearance from my primary care physician. I acknowledge eMD Men’s Clinic does not provide primary care physician services. I release liability from eMD Men’s Clinic’s medical provider/employee/staff/volunteer or instructor for any treatments/care/advice if it has not first been discussed or approved by/with my primary care physician by myself. I understand that it is my responsibility to keep my primary care physician aware/updated on my seeking of additional health care with/and/or/for traditional/alternative//homeopathy/naturopathic/integrative medicine.
If you are not in a state that our providers are licensed in, then we are only acting as a health and wellness consultant. We are not diagnosing or treating any medical conditions that you may have.
Testosterone Therapy/ Testosterone Possible Side Effects
It is very important for you to be aware of the potential risks, as well as the benefits, expected from the treatment when deciding on whether to begin Testosterone Replacement Therapy. You should also be aware of the alternatives to Testosterone Replacement Therapy, including not receiving treatment at all. The information provided to you herein is to help you decide whether what you are about to do is right for you. If you are unsure, then perhaps you should take some time to weigh your options or consult another health care provider.
Please review the following information, which discusses informed consent.
Any questions that you may have should be brought to our attention immediately. Your clinical provider will attempt to answer all of your questions to your satisfaction.
This is your consent for eMD Men’s Clinic, including any physician or nurse who works with the company, to begin treatment for Testosterone Replacement Therapy.
It has been explained to me, and I fully understand, occasionally there are complications with this treatment such as acne, breast enlargement, mood swings, as well as the following, but not limited to:
Sleep Disturbance — This is called sleep apnea and is more likely to occur with patients who have lung disease, or who are overweight.
Extra fluid in the body — This can cause problems for patients with heart, kidney, or liver disease.
Changes in cholesterol levels, red blood cell levels, PSA levels (prostate), liver function, and other hormone levels which will need to be monitored with periodic blood testing by your primary care physician (PCP).
Prostate enlargement — This may cause problems with urination.
I understand that I will have periodic blood tests to monitor my testosterone and PSA (prostate) levels.
I understand that there is no guarantee as to the results, and that if I stopped treatment, my condition may return, or worsen.
I have had an opportunity to discuss with eMD Men’s Clinic and its medical practitioner, my complete past medical and health history, including any serious problems and/or injuries. All of my questions concerning the risks, benefits, and alternatives have been answered. I am satisfied with the answers provided.
I understand that the information given me by eMD Men’s Clinic DOES NOT replace a full physical examination by my personal physician, PCP.
I agree to have my personal physician perform an annual full physical examination, including a digital rectal exam, lipid profile, cholesterol levels, complete blood count, and a comprehensive metabolic panel.
I fully understand the nature of the above information and the possible side effects have been explained to me.
I consent to a medical consultation fee and understand that the charges paid for Testosterone Replacement Therapy, as well as any other medication which may be prescribed for me and which I may elect to order, are final.
I consent to treatment by my treating doctor should I experience any inopportune symptoms.
I also understand that these services are considered elective treatment and are not covered by Medicare, and that any medications ordered by me are by law non-refundable
I hereby authorize eMD Men’s Clinic to maintain the medical records and medical charts for medical services provided to me, and I understand that these medical records and medical charts will not be released to any physician or anyone else without my prior written consent.
Lab testing: Which tests are needed will depend largely on your medical history. We might conduct a fasting glucose test to rule out your ED being a side effect of diabetes mellitus; a lipid profile or more extensive cardiovascular tests can rule out underlying vascular conditions. We will also evaluate your kidney, liver and thyroid function.
Measurement of luteinizing hormone (LH) may be helpful. LH levels vary according to the body’s need for testosterone. The hypothalamus regulates testosterone levels by releasing or inhibiting LH-releasing hormone (LHRH), which acts in the pituitary to produce LH. A high LH level associated with a low testosterone level implies primary testicular (Leydig cell) failure. Conversely, a low LH level associated with a low testosterone level suggests a central defect.
In some instances, prolactin levels may be helpful as well. A serum prolactin level is obtained if the patient has evidence of pituitary hyperfunction (eg, from a pituitary tumor) or if low serum testosterone levels have been documented.
A serum thyroid-stimulating hormone (TSH) evaluation is appropriate in selected patients.
Other blood tests
Additional useful screening studies include the following:
Hemoglobin A 1c
Serum chemistry panel
These studies should be considered unless the patient has had them performed recently and the results are available.
Measurement of prostate-specific antigen (PSA) levels may be appropriate if the patient is a candidate for prostate cancer screening. Such screening is controversial, however, and should be performed only after its risks and benefits have been reviewed with the patient
Performing a urinalysis is recommended. The presence of red blood cells (RBCs), white blood cells (WBCs), protein, or glucose can be important clues to a genitourinary disorder.
Hormonal investigation: Testosterone deficiency is one common yet often overlooked cause of ED, GCC will do advanced lab testing to exclude subtle testosterone deficiency, including measurements of bioavailable and free testosterone. Should treatment be necessary, we’ll correct your testosterone deficiency aggressively but safely.
I fully understand the nature of the above tests and the possible side effects. I consent to a medical consultation fee and understand that the cost associated is my responsibility if not included in the treatment plan. I consent to treatment by my treating doctor should I experience any inopportune symptoms. I also understand that these services are considered elective treatment and are not covered by Medicare, and that any medications ordered by me are by law non-refundable.
I understand the information provided on this form and agree to the foregoing. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures) set forth above has been adequately explained to me by my physician. I understand that I am free to withdraw my consent and to discontinue participation in their treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of intent to cancel or reschedule my appointment. I understand that I will incur the full fee for treatment, regardless of amount used due to wasted materials.
My signature or checking the box confirms that:
I have received all the information and explanation I desire concerning any treatment.
Nature of Hormone Replacement and Supplement Therapy
I hereby give my consent to treatment intended to enhance quality of life by improving health, vigor and vitality through the administration of hormone replacement therapy and/or nutritional supplements, including vitamins, minerals and anti-oxidants and/or medications designed to alter hormone levels. Ош physicians and staff members of Revita make no claims that hormone replacement therapy treats or cures any disease.
Regarding nutritional supplements, the goal is to raise levels of Vitamins, minerals, and anti-oxidants in order to maximize the physiologic processes in my body, minimize damage by naturally produced free radicals or support normal neurotransmitter function. Our physicians and staff members of Revita make no claims that any supplements treat or cure any disease.
Alternative Treatment Approach
The reasonable alternatives to these therapies have been explained to me and they include:
Leaving hormones and/ or neurotransmitter at current levels
Treating age related diseases as they occur as indicated by current Standard of Care.
Studies indicate that human identical hormones may not have the same side effects as non-human identical hormones. However, this may or may not be accepted by the medical community
Potential Risks of Therapy
I am aware that there are potential risks associated with hormone replacement therapy.
All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome when using:
Your eMD Men’s Clinic medical provider has prescribed Testosterone, in a cream form or intramuscularly, for you to use based on deﬁciency levels in your lab work. Male Testosterone Therapy may also include Chorionic Gonadotropin and an estrogen blocker.
Your eMD Men’s Clinic medical provider has explained the potential complications of Testosterone, which include but are not limited to soreness at the injection site, infection, overall muscle soreness, shrinkage of the testes themselves (however, GCC will be taking steps to be sure this does not occur), and trouble with the hypothalamus and pituitary axis.
Your eMD Men’s Clinic medical provider has explained the “Black box” warning for the testosterone cream, which includes that there can be an adverse effect in children and women who were inadvertently exposed to the testosterone through contact with another person treated with testosterone cream.
Potential side effects to synthetic testosterone or testosterone cypionate
Acne; bitter or strange taste in mouth; change in sex drive; fatigue; gum or mouth imitation; gum pain; gum tenderness or swelling; hair loss; headache. Severe allergic reactions (rash; hives; itching; difﬁculty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); breast growth or pain; change in the size or shape of the testicles; dark urine or light—colored bowel movements; depression or mood Changes; dizziness; gingivitis; interrupted breathing while sleeping; loss of appetite; nausea; painful or prolonged erection; stomach pain; swelling of the ankles or legs; urination problems; weight gain; yellowing of the skin or eyes.
If prescribed testosterone shots, they are generally given once a week in the buttocks area, but may be given more than that. You have been instructed by your medical provider and his/her staff on how to give this shot. Please follow the protocol exactly as we have described it. Always clean the area of skin to be injected with an alcohol pad, and use each needle only one time. After using a needle, recap it and discard it. By signing below, you agree that you understand the instructions that your eMD Men’s Clinic medical provider and his/her nursing staff have given you.
You may have to take an estrogen blocker which your eMD Men’s Clinic medical provider will prescribe for you after a month. This is usually taken twice a week or every other day. This is essentially necessary because as your testosterone levels increase, sometimes the testosterone will be converted to estrogen. This pill will offset that. Normally, if you are given therapeutic dosages of estrogen blocker, you will not need to cycle off the testosterone. However, depending on your estrogen levels (which will be checked through blood analysis), you may need to stop the testosterone.
You may have also been prescribed human Chorionic Gonadotropin or Clomid in order to keep your testes from shrinking and from shutting down its own natural production of testosterone. This is only given if you are only having these symptoms or the doctor believes you will beneﬁt from this medication. This is a complex issue; however, you will be monitored carefully and provided appropriate treatment.
These risks include water retention (which may result in leg swelling), elevated blood pressure, mild increase in fasting blood sugar, and occasional bruises at the injection site.
I may also develop infection at the injection site if I use improper techniques. Other possible side effects include testicular atrophy (shrinking) for men. All of these side effects may be reversible by dosage adjustment or stopping therapy.
The subcutaneous shot should be placed in and around your abdomen, and you have received adequate training to do this. Please follow the protocol exactly as we have described it. Always clean the area of skin to be injected with an alcohol pad, and use each needle only one time. After using a needle, recap it and discard it. By signing below you agree that you understand the instructions that your eMD Men’s Clinic medical provider and his/her nursing staff have given you.
I authorize eMD Men’s Clinic medical provider to perform this treatment.
I understand they will be assisted by other health professionals, as necessary, and agree to their participation in my care as it relates to nutrition, exercise, nutrient supplementation, and hormone modulation therapy,
I understand that no guarantee has been made to me regarding the outcome of this treatment.I hereby conﬁrm that the nature and purpose of portions of the aforementioned treatment are considered by some to be medically unnecessary and/or experimental because they are not aimed at treating a disease, and there are no long—term studies documenting the results. The risks involved and the possibilities of complications have been explained to me. I fully understand that the treatment to be provided may be considered experimental and unproven by scientiﬁctesting and peer—reviewed publication.
I assume full liability for any adverse effects that may result from the non—negligent administration of 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 procedure, except as that claim pertains to negligent administration of the procedure.
I understand that I will be responsible for injecting or administering the hormones prescribed to me. I will conform and comply with the recommended dose and methods of administration. I also agree to conform to the request for initial and subsequent blood tests, as required to monitor my hormone levels.
I certify that I am under the regular care of another physician for all other medical conditions.
I will continue under the care of my other physicians for any on—going medical conditions (not in the eMD Men’s Clinic medical provider’s areas of expertise).
I consent to the utilization of the results of my progress in any research study performed by eMD Men’s Clinic.
I understand that my personal information will be de-identiﬁed and that every effort will be made to protect my privacy.
I also understand that optional photographs that may be taken of me by eMD Men’s Clinic will not be used without my express written authorization.
I understand that I may suspend or terminate treatment at any time and hereby agree to immediately notify eMD Men’s Clinic medical provider of any such suspension or
termination. I also understand that the beneﬁts derived from anti—oxidant therapy may cease and those derived from hormone therapy and drugs that alter hormone levels may reverse if the therapy is discontinued.
HIPAA Privacy Form
Created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
eMD Men’s Clinic is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.
Regarding the use and disclosure of your health information in certain special circumstances. Please continue to read the circumstances as listed.
Lawsuits and similar proceedings in response to a court or administrative order.
If necessary to reduce or prevent a serious threat to your health and the safety or the health and safety of another individual or the Public. Only then would eMD Men’s Clinic make disclosures to a person or organization able to help prevent the threat.
Federal officials for intelligence and national security activities authorized by law.
For Workers Compensation and similar programs.
You have the right to request that eMD Men’s Clinic communicate with you about your health and related issues in a manner or at a certain location. You may ask that we contact you at home, rather than work.
You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including Patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to eMD Men’s Clinic.
You may ask eMD Men’s Clinic to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by eMD Men’s Clinic. To request an amendment, your request must be made in writing and submitted to eMD Men’s Clinic.
eMD Men’s Clinic must respond within 60 days. The Privacy Officer or the patient’s physician will provide this. If the physician believes the information is complete and accurate; the physician can refuse to make any changes.
To obtain a copy of this notice, please contact eMD Men’s Clinic.
eMD Men’s Clinic will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.