Disclaimers & Consents to Treat for ZYP Testosterone Replacement Therapy (TRT)
PATIENT CONSENT FOR HORMONE RESTORATION AND TREATMENT WITH ZYP Medical, LLC.If you have any questions, please feel free to ask us. By signing this liability and consent waiver you are agreeing that you have read and understand each of the following points:
If you are late or miss your appointment, you may be subject to a $50 fee.
Services must be paid for at the time of service.
Health insurance typically does not cover services provided at ZYP Medical, LLC. If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.
Testosterone is considered a controlled substance. I agree that I will take my medications as prescribed. I agree to follow my medical providers instructions. I also agree that I will not sell or share my prescriptions to other individuals.
I understand that treatments used at ZYP Medical, LLC might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional and supplemental counseling, and possibly weight loss treatment.
I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department.
I acknowledge that ZYP Medical, LLC and Joshua Peterson, ARNP, FNP-C are not my primary care provider unless I elect them so. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at ZYP Medical, LLC.
I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.
I understand that having an appointment with ZYP Medical, LLC does not necessarily entitle me to being issued a testosterone prescription. Every individual is different and it is at the medical provider’s discretion to issue a testosterone prescription.
I understand that I must maintain my follow up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is important that Joshua Peterson, ARNP, FNP-C manages my treatment and it is at their discretion to provide
I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.
I am voluntarily requesting treatment with ZYP Medical, LLC and Joshua Peterson, ARNP, FNP-C in regards to hormone replacement therapy and additional treatment modalities as determined by a mutual decision between myself and the medical provider even if my hormone levels are considered to be in normal range for my age based off of other medical society recommendations and guidelines.
I do not hold any medical practitioner of ZYP Medical, LLC responsible for performing prostate cancer screening, colon cancer screening, digital rectal exams, or other age-related preventive care. I agree that I will follow up with my primary care provider to obtain these screenings and I hold ZYP Medical, LLC and Joshua Peterson, ARNP, FNP-C harmless if an adverse event occurs during my treatment. I will ensure that my primary care provider provides the results of such screenings to ZYP Medical, LLC as this could change the treatment prescribed to me.
I have read, understand and agree to all of the above statements.
I hereby give my consent to evaluation and treatment by ZYP Medical, LLC, Joshua Peterson, ARNP, FNP-C, and any other provider associated with ZYP Medical, LLC for the following specified condition(s):
Andropause or associated symptoms (Including testosterone replacement, manipulating hormone levels including DHEA and estradiol).
Growth hormone abnormalities including decreased or suboptimal IGF -1, decreased or suboptimal Vitamin D-3 levels.
Nutritional deficiencies, Overweight/Obesity, B12 injections and anything else the medical provider deems is necessary.
In addition:
I acknowledge that treatment with testosterone, growth hormone stimulators, bioidentical hormone replacement therapy, B12, and thyroid optimization are considered off label use of the associated medications and have not been FDA approved for the use of health optimization, wellness, weight loss and/or for anti-aging purposes unless there is true medical necessity.
I agree to the administration of hormone replacement therapy, and/or nutritional supplements, and/or drugs designed to alter hormone levels which will meet my specific treatment objectives and to treat any specific diagnoses I might have.
Alternative Treatments I have been informed about alternative treatments and understand:
That we can leave the hormone levels alone.
We can use a natural approach such as weight loss and nutrition instead.
We can use alternative medications to increase your testosterone levels vs using prescription testosterone.
By signing or checking the box, I understand the alternative treatments and am choosing to consent to the treatment plan prepared for me by ZYP Medical, LLC to address the condition/conditions listed above.
Alternative Treatments I have been informed about alternative treatments and understand:
That we can leave the hormone levels alone.
We can use a natural approach such as weight loss and nutrition instead.
We can use alternative medications to increase your testosterone levels vs using prescription testosterone.
I understand the alternative treatments and am choosing to consent to the treatment plan prepared for me by ZYP Medical, LLC to address the condition/conditions listed above.
Side Effects and Potential Risks
• I acknowledge that common side effects of testosterone replacement are acne, possible balding, enlargement of the prostate, high blood pressure, high libido, enlargement of breast tissue (we will monitor and treat estrogen levels), testicular atrophy, fluid retention, infertility, and an increase in the thickness of your blood (hematocrit) due to the production of red blood cells (this will be monitored and treated if necessary).
• I understand that the possible theoretical/possible side effects for men on testosterone replacement can be an acceleration in the growth of prostate cancer, elevations in hematocrit which could potentially predispose one to a blood clot, and cardiovascular disease including heart attacks, strokes, and blood clots.
• Most of the common side effects resolve with time. Many of these can be treated by changing your testosterone dose and adding other medications.
By signing below, I acknowledge that I should take extreme precaution if I am to use topical testosterone products. If a child or women accidently is exposed to the testosterone cream/lotion on my body it could cause a significant increase in their hormone levels which could result in possible side effects.
Safety of Hormone Replacement
• Available data supports the safety of testosterone replacement therapy in men, and it is of the opinion of ZYP Medical, LLC and/or Joshua Peterson, ARNP, FNP-C that treatment is safe, but there still remains controversy regarding the correlation between the use of testosterone replacement therapy and cardiovascular events such as but not limited to: strokes, heart attacks, and blood clots. Some studies have shown correlations between testosterone replacement therapy and cardiovascular disease while others show no correlation or even a benefit in preventing cardiovascular disease.
By signing below, I understand that close monitoring is required by all patients to minimize and prevent any possible risks. I understand that ZYP Medical, LLC will monitor my blood work including hormone levels. I also understand that it is important to stay up to date with routine screening and health maintenance by my primary care provider to prevent and detect any possible life threatening diseases or conditions.
By signing below, I agree to obtain and remain up to date on all age-appropriate screenings including, but not limited to, digital rectal exams, colonoscopies, cardiac screenings, and any other type of recommended health screenings. I agree to obtain these screenings through the direction of my primary care provider and will not hold ZYP Medical, LLC, Joshua Peterson, ARNP, FNP-C, or any additional ZYP Medical, LLC staff responsible or liable for performing these health maintenance screenings or the treatment of any other conditions not relevant to my treatment goals with ZYP Medical, LLC.
If agreeable and electing to initiate treatment at ZYP Medical, LLC and I give permission to ZYP Medical, LLC and Joshua Peterson, ARNP, FNP-C and additional staff of ZYP Medical, LLC to begin treatment without knowing results of age-appropriate and health maintenance screenings. In doing so, I release ZYP Medical, LLC, Joshua Peterson, ARNP, FNP-C and other healthcare practitioners of any claims of liability for cardiovascular events, prostate cancer, breast cancer, testicular cancer, and/or colon cancer. Further, I agree to immediately notify ZYP Medical, LLC, Joshua Peterson, ARNP, FNP-C and additional staff of ZYP Medical, LLC of any abnormal findings on any health screenings done by my primary care provider.
Any questions I have regarding this treatment have been answered to my satisfaction. I understand that I will be responsible for administering the hormones and/or medications prescribed to me if I do not have them administered to me in clinic. I also promise to comply with the dosages and frequency of medications prescribed to me.I certify that I am under the regular care of a primary care provider or a specialist for any other conditions I might have or am found to have. I will consult with my primary care provider or specialist in regards to any other condition I might have. I understand that if I do not have a primary care provider, that I will be encouraged to seek one out. I acknowledge that I am seeking care at ZYP Medical, LLC for the specific services ZYP Medical, LLC offers. I acknowledge I am not wanting to establish primary care with ZYP Medical, LLC and I am here for specialized care including testosterone replacement, hormone restoration, etc.I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks associated with hormone restoration and treatment with ZYP Medical, LLC. I release any claim in court or any type of complaint that could result from treatment with ZYP Medical, LLC, Joshua Peterson, NP and any other staff associated with ZYP Medical, LLC and will not hold liable any provider or staff of ZYP Medical, LLC.I understand that treatment modalities utilized by ZYP Medical, LLC might not be supported by scientific/medical literature and could be seen as experimental or based off anecdotal claims. Many medical providers, including endocrinologists and urologists, might see these types of treatments and not medically necessary.
I hereby authorize ZYP Medical, LLC,Joshua Peterson, NP and additional staff of ZYP Medical, LLC to evaluate and treat conditions that I have consented for. I consent to obtaining blood work before my initial evaluation so hormone levels can be monitored and appropriate treatment can be prescribed. I certify that I am signing this under my free will and am competent to make my own medical decisions.
I the patient agree to indemnify, defend, protect, and hold harmless Joshua Peterson, NP, medical providers employed by ZYP Medical, LLC and ZYP Medical, LLC; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, Joshua Peterson, NP, medical providers employed by ZYP Medical, LLC and ZYP Medical, LLC; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, of Joshua Peterson, NP, ZYP Medical, LLC; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Joshua Peterson, NP or ZYP Medical, LLC. I am aware of the potential side effects associated with the above treatments, accept all the risks involved in taking the medication and will not seek indemnification or damages from the indemnified parties.