Testosterone Consent Form

Consent and Acknowledgments

By signing below, I acknowledge and agree to the following:

1. This is my consent for Wright Health and Wellness, including any physician or nurse who works with the company, to begin treatment for Testosterone Replacement Therapy.

2. It has been explained to me, and I fully understand, that occasionally there are complications with this treatment such as acne, breast enlargement, and mood swings, as well as the following:

   1. Extra fluid in the body – This can cause problems for patients with heart, kidney, or liver disease.

   2. Sleep disturbance – This is called sleep apnea and is more likely to occur with patients who have lung disease or are overweight.

   3. Prostate enlargement – This may cause problems with urinating.

   4. Changes in cholesterol levels, red blood cell levels, PSA levels, liver function enzymes, and other hormone levels, which will be monitored with periodic blood tests.

3. I understand that I will have periodic blood tests to monitor my blood levels.

4. I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse.

5. I have had an opportunity to discuss with Wright Health and Wellness and its medical practitioners 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.

6. I understand that the physical exam by Wright Health and Wellness does NOT replace a full physical exam by a personal physician.

7. I agree to have my personal physician perform a yearly full physical exam including a digital rectal exam, lipid profile, cholesterol levels, and a comprehensive metabolic panel. If I do not have a personal physician, Wright Health and Wellness will assist in locating one for me.

8. I understand that prolonged TRT therapy may reduce ejaculate volume and reduce sperm count, possibly affecting fertility.

9. I understand that there may be an increased chance of hair loss or thinning.

Our Treatment Approach

Our comprehensive, standardized treatment protocol allows us to use the lowest effective dose to minimize side effects and maximize benefits of TRT for all patients while maintaining strict safety measures. Our general approach to all patients — and especially ones with a history of cardiovascular disease and/or advanced age — is to make sure they are first appropriate candidates for therapy, to make sure the patient understands all the risks and benefits involved in TRT, and to proceed with caution and adjust dosing as needed, depending on the individual risk factors.

No Other Testosterone Supplementation Agreement

I agree that, while a patient of Wright Health and Wellness, I will not take any type of anabolic steroids, testosterone gels, hormone “boosters,” pro-hormones, or any additional testosterone supplementation not provided by Wright Health and Wellness during my treatment plan.