<p>INFORMED CONSENT FOR HORMONE REPLACEMENT THERAPY</p><p>I. PROCEDURES AND ALTERNATIVES</p><p>1. I, ______(Patient or patient guardian) </p><p>AUTHORIZE DR. ______(Dr.’s Name) and</p><p>Angela Pressman, Licensed Pharmacist, to assist me in a Hormone Replacement Therapy Program.</p><p>2. I have read and understand the statement that follows: “Usage of Hormone Replacement Therapy has not been systematically studied; and it is possible, as with most other medications, that there could be serious effects (as noted below). You must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible benefits that Hormone Replacement Therapy may provide to you.”</p><p>3. I understand that it is my responsibility, to carefully follow the instructions and report to my primary physician, and/or gynecologist, and/or endocrinologist, and/or urologist any significant medical problems that I believe may be related to my Hormone Replacement Therapy as soon as reasonably possible. Furthermore, I agree to:  Have an annual physical examination  Appropriate laboratory testing  Schedule regular blood work  Follow up with my Gynecologist and or family doctor  Obtain regular mammograms, (ultrasound if necessary), PAP Smear/ultrasound ( endometrial lining)  Follow up with medical specialist (example: Endocrinologist, Urologist) as advised  Obtain regular prostate exams (male patients)</p><p>II. RISKS OF HORMONE REPLACEMENT THERAPY:</p><p>I UNDERSTAND THIS AUTHORIZATION IS GIVEN WITH THE KNOWLEDGE THAT HORMONE REPLACEMENT THERAPY INVOLVES SOME HEALTH RISKS AND HAZARDS. THE MORE COMMON RISKS INCLUDE: HEART DISEASE, MYOCARDIAL INFRACTION, STROKE AND BREAST CANCER; FOR MALES: EXACERBATION OF PROSTATE CANCER. THESE AND OTHER POSSIBLE RISKS COULD, ON OCCASION, BE SERIOUS OR FATAL.</p><p>III. NO GUARANTEES:</p><p>I UNDERSTAND THAT THERE ARE NO GUARANTEES OR ASSURANCES THAT HORMONE REPLACEMENT THERAPY WILL BE SUCCESSFUL. HOWEVER, MOST PATIENTS HAVE A HIGH SUCCESS RATE WITH THIS TREATMENT PROGRAM.</p><p>1 IV. PATIENT’S CONSENT:</p><p>I HAVE READ AND FULLY UNDERSTAND THIS CONSENT FORM; AND I ACKNOWLEDGE THAT I SHOULD NOT SIGN THIS FORM IF ALL ITEMS HAVE NOT BEEN EXPLAINED OR ANY QUESTIONS I HAVE CONCERNING THEM HAVE NOT BEEN ANSWERED TO MY COMPLETE SATISFACTION. I HAVE BEEN URGED TO TAKE ALL THE TIME I NEED TO READ AND UNDERSTAND THIS FORM AND TO TALK WITH MY DOCTOR AND PHARMACIST REGARDING RISKS ASSOCIATED WITH THE PROPOSED TREATMENT.</p><p>I HIREBY RELEASE PILL BOX, ALL ITS EMPLOYEES AND PHARMACISITS FROM ANY AND ALL LIABILITY WHATSOEVER ASSOCIATED WITH OR CONNECTED TO MY HORMONE REPLACEMENT THERAPY CONSULTATION AND/OR USE OF HHORMANE REPLACEMENT THERAPY. I ACKNOWLEDGE THAT I AM LEGALLY RESPONSIBLE FOR AND AWARE OF POTENTIAL SIDE EFFECTS ASSOCIATED WITH HORMONE REPLACEMENT THERAPY. I UNDERSTAND THAT NO DOCTOR, NURSE, PHARMACIST, OR ADMINISTRATIVE PERSONNEL CAN GUARANTEE THAT HORMONE REPLACEMENT THERAPY WILL PROVIDE THE RESULTS I SEEK. </p><p>I AM PARTICIPATING IN THE PROGRAM BY MY OWN CHOICE. </p><p>WARNING:</p><p>IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF HORMONE REPLACEMENT THERAPY OR ANY QUESTIONS WHATSOEVER CONCERNING HORMONE REPLACEMENT THERAPY OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR AND/OR PHARMACIST NOW BEFORE SIGNING CONSENT FORM .</p><p>PATIENT NAME______DATE______(PRINT NAME)</p><p>PATIENT ______(SIGNATURE)</p><p>V. PHYSICIAN AND/OR PHARMACIST DECLARATION I HAVE EXPLAINED THE CONTENTS OF THIS DOCUMENT TO THE PATIENT AND HAVE ANSWERED ALL THE PATIENT’S RELATED QUESTIONS. AFTER BEING ADEQUETELY INFORMED, THE PATIENT HAS CONSENTED TO HORMONE REPLACEMENT THERAPY.</p><p>PHYSICIAN’S PRINTED NAME______</p><p>PHYSICIAN’S SIGNATURE______DATE______</p><p>AND/OR</p><p>PHARMACIST’S PRINTED NAME______</p><p>PHARMACIST’S SIGNATURE ______DATE______2</p>