Male new patient package

Male New Patient Package
The contents of this package are your first step to restore your vitality. Please take time to read this careful y and answer al the questions as completely as possible. We look forward to partnering with you to help you feel your best again. Thank you for your interest in BioTe Medical®. In order to determine if you are a candidate for bio- identical testosterone pel ets, we need laboratory and your history forms. We will evaluate your information prior to your consultation to determine if BioTe Medical® can help you live a healthier life. Please complete the
following tasks before your appointment:

2 weeks or more before your scheduled consultation: Get your FASTING blood lab drawn at any
Quest Laboratory/ or LabCorp Lab. IF YOU ARE NOT INSURED OR HAVE A HIGH DEDUCTIBLE, CALL OUR
OFFICE FOR SELF-PAY BLOOD DRAWS. We request the tests listed below. It is your responsibility to find out if
your insurance company will cover the cost, and which lab to go to. Please note that it can take up to two
weeks for your lab results to be received by our office. Please fast for 12 hours prior to your blood draw.
Your fasting blood work panel MUST include the following tests:
___ Estradiol ___ Testosterone Free & Total ___ PSA Total ___ TSH ___ T4, Total ___ T3, Free ___ T.P.O. Thyroid Peroxidase ___ CBC ___ Complete Metabolic Panel ___ Vitamin D, 25-Hydroxy ___ Lipid Panel (Optional) Male Post Insertion Labs Needed at 4 Weeks:
___ Estradiol ___ Testosterone Free & Total ___ PSA Total (If PSA was borderline on first insertion) ___ CBC Male Patient Questionnaire & History
Name: ____________________________________________________________Today’s Date: ____________ Date of Birth: ______________ Age: ________ Occupation: _________________________________________ Home Address: _____________________________________________________________________________ City: ___________________________________________________ State: __________ Zip: _______________ Home Phone: _____________________ Cell Phone: _____________________ Work: ____________________ E-Mail Address: ______________________________________ May we contact you via E-Mail? ( ) YES ( ) NO
In Case of Emergency Contact: ________________________________ Relationship: _____________________ Home Phone: _____________________ Cell Phone: _____________________ Work: ____________________ Primary Care Physician’s Name: ___________________________________ Phone: ______________________ Address: __________________________________________________________________________________ Marital Status (check one): ( ) Married ( ) Divorced ( ) Widow ( ) Living with Partner ( ) Single In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment. Spouse’s Name: _____________________________________ Relationship: ____________________________ Home Phone: _____________________ Cell Phone: _____________________ Work: ____________________ Social:
( ) I am sexually active.
( ) I want to be sexually active.
( ) I have completed my family.
( ) I have used steroids in the past for athletic purposes.
Habits:
( ) I smoke cigarettes or cigars ______________________ a day.
( ) I drink alcoholic beverages ______________________ per week.
( ) I drink more than 10 alcoholic beverages a week.
( ) I use caffeine ______________________ a day.
Medical History
Any known drug allergies: ____________________________________________________________________ Have you ever had any issues with anesthesia? ( ) Yes ( ) No If yes please explain: _________________________________________________________________________ Medications Currently Taking: _________________________________________________________________ Current Hormone Replacement Therapy: ________________________________________________________ Past Hormone Replacement Therapy: ___________________________________________________________ Nutritional/Vitamin Supplements: ______________________________________________________________ Surgeries, list al and when: __________________________________________________________________ Other Pertinent Information: __________________________________________________________________ __________________________________________________________________________________________ Medical Illnesses:
( ) Trouble passing urine or take Flomax or Avodart. ( ) Blood clot and/or a pulmonary emboli. ( ) Chronic liver disease (hepatitis, fatty liver, cirrhosis). ( ) Diabetes. ( ) Cancer (type): ____________________________ I understand that if I begin testosterone replacement with any testosterone treatment, including testosterone pellets, that I will produce less testosterone from my testicles and if I stop replacement, I may experience a temporary decrease in my testosterone production. Testosterone Pellets should be completely out of your system in 12 months. By beginning treatment, I accept all the risks of therapy stated herein and future risks that might be reported. I understand that higher than normal physiologic levels may be reached to create the necessary hormonal balance. ___________________________________________ _____________________________________________________ ______________________ Print Name
Signature
Today’s Date
BHRT CHECKLIST FOR MEN
Symptom (please check mar k)
ever M ild Mod erate
Decline in general well being
Joint pain/muscle ache
Excessive sweating
Sleep problems
Increased need for sleep
Irritability
Nervousness
Depressed mood
Exhaustion/lacking vitality
Declining Mental Ability/Focus/Concentration
Feeling you have passed your peak
Feeling burned out/hit rock bottom
Decreased muscle strength
Weight Gain/Bel y Fat/Inability to Lose Weight
Breast Development
Shrinking Testicles
Rapid Hair Loss
Decrease in beard growth
New Migraine Headaches
Decreased desire/libido
Decreased morning erections
Decreased ability to perform sexual y
Infrequent or Absent Ejaculations
No Results from E.D. Medications
Other symptoms that concern you:
Testosterone Pel et Insertion Consent Form
Bio-identical testosterone pellets are concentrated, compounded hormone, biological y identical to the testosterone that is made in your own body. Testosterone was made in your testicles prior to “andropause.” Bio-identical hormones have the same effects on your body as your own testosterone did when you were younger. Hormone pellets are made from soy and hormone replacement using pel ets has been used in Europe, the US and Canada since the 1930’s. Your risks are similar to those of any testosterone replacement but may be lower risk than alternative forms. During andropause, the risk of not receiving adequate hormone therapy can outweigh the risks of replacing testosterone with pellets. Risks of not receiving testosterone therapy after andropause include but are not limited to:
Arteriosclerosis, elevation of cholesterol, obesity, loss of strength and stamina, generalized aging, osteoporosis, mood disorders, depression, arthritis, loss of libido, erectile dysfunction, loss of skin tone, diabetes, increased overal inflammatory processes, dementia and Alzheimer’s disease, and many other symptoms of aging. CONSENT FOR TREATMENT: I consent to the insertion of testosterone pel ets in my hip. I have been informed that I may experience
any of the complications to this procedure as described below. Surgical risks are the same as for any minor medical procedure and
are included in the list of overall risks below:
Bleeding, bruising, swel ing, infection and pain. Lack of effect (typical y from lack of absorption). Thinning hair, male pattern baldness. Increased growth of prostate and prostate tumors. Extrusion of pellets. Hyper sexuality (overactive Libido). Ten to fifteen percent shrinkage in testicle size. There can also be a significant reduction in sperm production. There is some risk, even with natural testosterone therapy, of enhancing an existing current prostate cancer to grow more rapidly. For this reason, a rectal exam and prostate specific antigen blood test is to be done before starting testosterone pel et therapy and wil be conducted each year thereafter. If there is any question about possible prostate cancer, a fol ow-up with an ultrasound of the prostate gland may be required as wel as a referral to a qualified specialist. While urinary symptoms typical y improve with testosterone, rarely they may worsen, or worsen before improving. Testosterone therapy may increase one’s hemoglobin and hematocrit, or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin & Hematocrit.) should be done at least annual y. This condition can be reversed simply by donating blood periodical y. BENEFITS OF TESTOSTERONE PELLETS INCLUDE:
Increased libido, energy, and sense of well-being. Increased Muscle mass and strength and stamina. Decreased frequency and severity of migraine headaches. Decrease in mood swings, anxiety and irritability (secondary to hormonal decline). Decreased weight (Increase in lean body mass). Decrease in risk or severity of diabetes. Decreased risk of heart disease. Decreased risk of Alzheimer’s I have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pel et therapy. Al of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications, including one or more of those listed above. I accept these risks and benefits and I consent to the insertion of hormone pel ets under my skin. This consent is ongoing for this and al future pel et I understand that payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pel et therapy to be a covered benefit and my insurance company may not reimburse me, depending on my coverage. I acknowledge that my provider has no contracts with any insurance company and is not contractual y obligated to pre-certify treatment with my insurance ___________________________________________ _____________________________________________________ ______________________ Print Name
Signature
Today’s Date
Hormone Replacement Fee Acknowledgment
Preventative medicine and bio-identical hormone replacement is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as Medical Doctors and RN’s or NP’s, insurance does not recognize it as necessary medicine BUT is considered like plastic surgery (esthetic medicine) and therefore is not covered by health insurance in most cases. This practice is not associated with any insurance companies, which means they are not obligated to pay for our services (blood work, consultations, insertions or pellets). We require payment at time of service and, if you choose, we wil provide a form to send to your insurance company and a receipt showing that you paid out of pocket. WE WILL NOT, however, communicate in any way with insurance companies. The form and receipt are your responsibility and serve as evidence of your treatment. We will not call, write, pre-certify, or make any contact with your insurance company. Any fol ow up letters from your insurance to us will be thrown away. If we receive a check from your insurance company, we will not cash it, but instead return it to the sender. Likewise, we will not mail it to you. We will not respond to any letters or calls from your insurance company. For patients who have access to Health Savings Account, you may pay for your treatment with that credit or debit card. This is the best idea for those patients who have an HSA as an option in their medical coverage. New Patient Consult Fee ………………………………………….……….…. $125.00
Male Hormone Pel et Insertion Fee…………….…………………………. $600.00
Male Hormone Pel et Insertion Fee (over 2000mg).….$700.00
We accept the fol owing forms of payment:
Master Card, Visa, Discover, American Express, Personal Checks and Cash.
___________________________________________ _____________________________________________________ ______________________ Print Name
Signature
Today’s Date
Post-Insertion Instructions for Men
• Your insertion site has been covered with two layers of bandages. Remove the outer pressure bandage any time after 3 to 4 hours. You may replace it with a bandage to catch any anesthetic that may ooze out. The inner layer is either waterproof foam tape or steri-strips they should not be removed before 7 days. • We recommend putting an ice pack on the insertion area a couple of times for about 20 minutes each time over • Do not take tub baths or get into a hot tub or swimming pool for 3 days. You may shower but do not scrub the site until the incision is well healed (about 7 days). • No major exercises for the incision area for the next 7 days, this includes running, riding a horse, etc. • The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days. Don’t worry…. this is normal. • The insertion site may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief, 50 mg. orally every 6 hours. Caution this can cause drowsiness! • You may experience bruising, swelling, and/or redness of the insertion site which may last from a few days up to • You may notice some pinkish or bloody discoloration of the outer bandage. This is normal. • If you experience bleeding from the incision, apply firm pressure for 5 minutes. • Please call if you have any bleeding (not oozing) or pus coming out of the insertion site that is not relieved by • Remember to go for your post-insertion blood work 4 weeks after the insertion. • Most men will need re-insertions of their pellets 5-6 months after their initial insertion. • Please cal as soon as symptoms that were relieved from the pellets start to return to make an appointment for a re-insertion. The charge for the second visit will be only for the insertion and not a consultation unless you would like to discuss treatment and additional hormonal health matters. Reminders:
Please have your labs rechecked:
Prescriptions:
___________________________________________ _____________________________________________________ ______________________ Print Name
Signature
Today’s Date
WHAT MIGHT OCCUR AFTER A PELLET INSERTION
A significant hormonal transition wil occur in the first four weeks after the insertion of your hormone pelets. Therefore, certain changes might develop that can be bothersome. • FLUID RETENTION: Testosterone stimulates to the muscle grow and retain water which may result in
a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especial y during hot, humid weather conditions. • SWELLING of the HANDS & FEET: This is common in hot and humid weather. It may be treated by
drinking lots of water, reducing your salt intake, taking cider vinegar capsules daily, (found at most health and food stores) or by taking a mild diuretic, which the office can prescribe. • MOOD SWINGS/IRRITABILITY: These may occur if you were quite deficient in hormones. They wil
disappear when enough hormones are in your system. • FACIAL BREAKOUT: Some pimples may arise if the body is very deficient in testosterone. This lasts a
short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please cal the office for suggestions and possibly prescriptions. • HAIR LOSS: Is rare and usual y occurs in patients who convert testosterone to DHT. Dosage adjustment
generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases. • HAIR GROWTH: Testosterone may stimulate some growth of hair on your chin, chest, nipples and/or
lower abdomen. This tends to be hereditary. You may also have to shave your legs and arms more often. Dosage adjustment generally reduces or eliminates the problem. ___________________________________________ _____________________________________________________ ______________________ Print Name
Signature
Today’s Date
OFFICE USE ONLY MALE INTAKE FORM
NAME: ________________________________________________________________ DATE: ______________
Height: ________ Weight: ________Blood Pressure: ________Temperature: ________
CURRENT MEDICATIONS: _____________________________________________________________________________
__________________________________________________________________________________________________ SURGERY/PAST MEDICAL HISTORY: ___________________________________________________________________
__________________________________________________________________________________________________ SYMPTOMS: _______________________________________________________________________________________
__________________________________________________________________________________________________ Estradiol: ________ Testosterone: ________ Free Test: ________ PSA: ________ Vitamin D: ________
TSH: ________ Free T3: ________ CBC: ________ Chem Panel: ________
LDL: ________ HDL: ________ Triglycerides: ________
PLAN:
This patient presents today for hormone pellets. The procedure, risks, benefits and alternatives were explained to the
patient. Questions were answered and a consent form for the insertion of testosterone pellet implants was signed. An
area in the hip was prepped with Betadine swabs. A sterile drape was applied. 1% Lidocaine with epinephrine and
sodium bicarbonate was injected to anesthetize the area. A small transverse incision was made using a number 11
blade. The trocar with cannula was passed through the incision into the subcutaneous tissue. Testosterone pellet(s)
were inserted through the cannula into the subcutaneous tissue. Bleeding was minimal. Steri-strips and/or Foam Tape
were applied. A sterile dressing was applied. The patient tolerated the procedure well. Postoperative instructions were
reviewed and a copy given to the patient. Pellets used are as follows.
TREAT WITH:
Testosterone: ___________ MG’s Testosterone Lot Numbers: _____________________________________________
Femara: ________________________ Arimidex: ________________________ DIM: _____________________________
Vitamin D: ________________________ Thyroid________________________
COMMENTS:_______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
OFFICE USE ONLY MALE PATIENT TREATMENT FORM
NAME: _______________________________________________
DATE _______________
SYMPTOMS/NOTES:
__________________________________________________________________________________________________ __________________________________________________________________________________________________ PROCEDURE REPORT:
The procedure, risks, benefits and alternatives were explained to the patient. Questions were answered and a consent form for the insertion of testosterone pellet implants was signed. An area in the hip was prepped with Betadine swabs. A sterile drape was applied. 1% Lidocaine with epinephrine and sodium bicarbonate was injected to anesthetize the area. A small transverse incision was made using a number 11 blade. The trocar with cannula was passed through the incision into the subcutaneous tissue. Testosterone pel et(s) were inserted through the cannula into the subcutaneous tissue. Bleeding was minimal. Steri-strips and/or Foam Tape were applied. A sterile dressing was applied. The patient tolerated the procedure well. Postoperative instructions were reviewed and a copy given to the patient. Weight ________ Testosterone pel et Lot # ____________ Insertion site: Left Hip ( ) Right Hip ( ) DATE _______________
SYMPTOMS/NOTES:
__________________________________________________________________________________________________ __________________________________________________________________________________________________ PROCEDURE REPORT:
The procedure, risks, benefits and alternatives were explained to the patient. Questions were answered and a consent form for the insertion of testosterone pellet implants was signed. An area in the hip was prepped with Betadine swabs. A sterile drape was applied. 1% Lidocaine with epinephrine and sodium bicarbonate was injected to anesthetize the area. A small transverse incision was made using a number 11 blade. The trocar with cannula was passed through the incision into the subcutaneous tissue. Testosterone pellet(s) were inserted through the cannula into the subcutaneous tissue. Bleeding was minimal. Steri-strips and/or Foam Tape were applied. A sterile dressing was applied. The patient tolerated the procedure well. Postoperative instructions were reviewed and a copy given to the patient. Weight ________ Testosterone pel et Lot # ____________ Insertion site: Left Hip ( ) Right Hip ( ) New Male Patient Package Page Number: 10

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