Authorization to Consent to Medical Treatment

The following are forms for you to review, complete, and sign during your consultation.

1. Consent for Trimix Therapy treatment

2. Consent for Low Testosterone Therapy treatment

AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT

Your Name, Date of Birth, Address ______________________________

I hereby authorize and consent to the following medical treatment by Craig Keyes, MD or John Gerard, MD, including being the recipient of an activating compound agent called “Trimix” into my penis area by injection, and including: 

  1. a physical examination and determination of overall general health, including review of medical history and conditions that may relate to the appropriateness and effectiveness of receiving a trimix dosage;
  2. determination of appropriateness of the participant for the injection;
  3. determination of the appropriate dosage of the agent;

Such may also include, if necessary for any unforeseen reason:

  • transportation by ambulance;
  • x-rays;
  • diagnoses of any related conditions or unforeseen complications as may arise; 
  • hospitalization; 
  • medication as needed for relief of any unanticipated symptoms.

I agree that I am of sound mind, and agree to this Consent knowingly, voluntarily and with full understanding, and that such Consent will be effective up to and including the 1st day of January, 2018.

Dr. Keyes and or Dr. Gerard have discussed with me the potential risks and complications of treatment, including bruising, infection at the site of injection, and priapism (prolonged penile erection) and I understand and accept those risks.

Any questions or concerns regarding this authorization may be directed to Dr. Keyes, 321 W. 110th St. Suite 15A, NY, NY 10026  consent@revformen.com

By signing my name and signature to this form, I affirm and agree with its aforementioned terms this date of _____________.

PARTICIPANT:

_______________________________
Print Name
________________________________
Signature

 

Physician:
________________________________
Print Name
________________________________
Signature

AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT

Your Name, Date of Birth, Address ______________________________

A Few Things to Know about Testosterone Replacement Therapy:

It is important to understand that medicine is an inexact science. Although we will carry out your treatment carefully, results can vary in their degree of success. It is quite natural for a patient undergoing Testosterone Replacement Therapy (“TRT”) to want to know that everything will turn out well. Most of the time it will be fine, however, it is necessary to discuss its potential risks, as well as its benefits. You should also be aware of the alternatives to testosterone replacement therapy, including not receiving treatment.

This form is intended to document that you understand the information regarding TRT, so that you can make an informed decision about your condition and your options.

Based on your symptoms and the results for laboratory testing, Dr. Craig Keyes/Dr. John Gerard may/has recommended TRT. The goal of TRT is to optimize your testosterone levels to alleviate the symptoms of low testosterone. Testosterone is not administered for muscle building or to enhance athletic performance, but to relieve symptoms and improve quality of life.

Testosterone is not stored by the body, so to maintain healthy levels, it needs to be administered in timed intervals and in appropriate dosages. Testosterone can be administered in a number of ways. There are pills, transdermals (topical creams, gels, patches and liquids), sublinguals or troches (under the tongue or inside the cheek), and intramuscular injections.

The full health benefits for testosterone are associated with restoring the levels to the “optimal” range, and not the “normal-for-age range. This means raising your testosterone level to the upper-half of the reference (physiologic) range in our opinion. The reference range is 250-1100 ng/dl, so your optimal range may be 700 -1100 ng/dl. 

Possible complications of non-treatment may include a worsening of your symptoms and increasing your risk of conditions associated with testosterone deficiency including heart disease, diabetes, Alzheimer’s, osteoporosis, depression and premature death.

All medical treatments have potential side effects. However, there are few potential side effects with TRT since we simply are restoring something inherently natural to the body (testosterone), and we are restring it to healthy physiologic levels only. The goal is to make sure the testosterone level is high enough to achieve benefits, but not so high to create serious problems. The most common side effects generally are mild and temporary, and may include:

  • Overproduction of red blood cells: This also is known as erythrocytosis. Testosterone can stimulate bone marrow to produce more red blood cells. This sometimes can cause the blood to become too viscous (thick). When this side effect occurs, it is reversed by donating blood every two to three months. 
  • Decreased testosterone and/or sperm production, and testicular shrinkage: Testosterone can sometimes cause a reduction in testosterone and/or cell production and, rarely, mild shrinkage of the testicles. This is prevented by twice weekly microinjections of prescription HCG (Human Chorionic Gonadotropin) which we can provide.
  • Fluid retention: This is also known as edema. A small number of men on testosterone therapy may retain fluid. This is reversed by reducing the dosage of testosterone and/or by the use foods that have a diuretic-like effect.
  • Acne: Testosterone therapy may increase oil production in the sebaceous glands in the skin, leading to acne. Such acne is mild and is more likely to occur if the body was extremely deficient in testosterone. This lasts a short time and is reversed with good face washing, astringents and skin toner.
  • Breast or nipple sensitivity: When this occurs, it is due to testosterone being converted to excess estrogen in the body. The sensitivity is due to the increased blood supply to the breast tissue that estrogen causes. This may be prevented by taking an estrogen-blocking medication or botanical which we can provide.
  • Hair thinning: When this occurs, it is due to testosterone being converted to excess amounts of DHT (dihydrotestosterone) in the hair follicles. This is managed by taking over-the-counter tocotrienols (a special form of vitamin E) and biotin (a B vitamin), botanical therapy, or by using a DHT-blocking shampoo which we can prescribe.

Directions: Initial beside each statement that you have read, understand, and agree with. 

____1. This is my consent for Dr. Craig Keyes/Dr. John Gerard, including any physician or nurse or assistant who works with them, 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, Mood Swings, as well as the following (#3 -#7):

____3. Extra fluid in the body-This can cause problems for patients with heart, kidney, or liver disease.

____4. Sleep disturbance -This is called sleep apnea and is more likely to occur with patients who have lung disease or are overweight.

____5. Prostate enlargement -This may cause problems with urinating.

____6. 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.

____7. I understand that I will have periodic blood tests to monitor my blood levels.

____8. I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse.

____9. I have had an opportunity to discuss with Dr. Craig Keyes/Dr. John Gerard my complete past medical and health history including any serious problems and/or injuries. All my questions concerning the risks, benefits, and alternatives have been answered. I am satisfied with the answers.

____10. I understand that the physical exam by Dr. Craig Keyes/Dr. John Gerard does NOT replace a full physical exam by a personal physician.

____11. I agree to have my personal physician perform a yearly full physical exam including a digital rectal exam. If I do not have a personal physician, Dr. Keyes/Dr. Gerard will assist in locating one for me.

____12. INDEMNIFICATION CLAUSE: I agree to indemnify, defend, protect and hold harmless Dr. Keyes/Dr. Gerard ("Indemnified Parties") from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paid by the Indemnified Parties in connection with, resulting from or arising out of, directly or indirectly, Dr. Keyes/Dr. Gerard 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 Dr. Keyes/Dr .Gerard harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Dr. Keyes/Dr. Gerard. I am aware of the potential side effects associated with the above-described treatment, accept all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties. This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void and of no effect. If any provision of this Agreement or the application thereof to any person or circumstances is held invalid or unenforceable in any jurisdiction, the remainder hereof, and the application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end the provisions of this Agreement shall be severable.

____13. I acknowledge, understand, and agree to the terms and conditions disclosed herein, including, but not limited to the indemnification clause for any liabilities arising out of the TRT rendered by Dr. Keyes/Dr. Gerard.

Any questions or concerns regarding this authorization may be directed to Dr. Keyes, 321 W. 110th St. Suite 15A, NY, NY 10026  consent@revformen.com

By signing my name and signature to this form, I affirm and agree with its aforementioned terms this date of _____________.

PARTICIPANT:

_______________________________
Print Name
________________________________
Signature

 

Physician:
________________________________
Print Name

________________________________
Signature