TRT Consent Form – CY Men’s Health Clinic

CY Men’s Health Clinic — Testosterone Replacement Therapy Consent

Informed consent for testosterone replacement therapy, controlled-substance acknowledgment, fertility counseling, safety monitoring, patient responsibilities, and handwritten signature capture.

TRT Consent Controlled Medication Signature Pad Chart Summary

1. Patient Information

Patient Name

Date of Birth

Age

Consent Date

Phone

Preferred Language

Visit Type

Patient Location if Telemedicine

Provider Name

2. Purpose of Testosterone Therapy

I understand that testosterone replacement therapy, also called TRT, may be prescribed when a licensed clinician determines that I have symptoms consistent with testosterone deficiency and laboratory evidence supporting low testosterone.

I understand that TRT is not intended for bodybuilding, athletic enhancement, cosmetic muscle gain, or non-medically indicated hormone optimization.

I understand that the goal of treatment is to improve clinically significant symptoms while maintaining testosterone levels in a safe, medically appropriate range.

Patient Acknowledgment

I understand the purpose of TRT. I understand TRT is for medical indication only. I understand TRT is not for bodybuilding or athletic enhancement.

3. Diagnosis and Required Evaluation

I understand that my clinician may require symptoms, history, physical assessment when appropriate, and laboratory testing before starting or continuing TRT.

I understand that testosterone levels can fluctuate and that my clinician may require two separate early-morning testosterone levels before starting treatment, unless I am being evaluated for continuation of care with adequate prior records.

I understand that additional labs may include CBC/hematocrit, CMP, PSA when appropriate, lipid panel, A1c, LH, FSH, prolactin, SHBG, free testosterone, estradiol, and thyroid testing when clinically indicated.

Patient Acknowledgment

I understand labs may be required before treatment. I understand two early-morning testosterone levels may be required. I understand treatment may be delayed if labs/records are incomplete.

4. Potential Benefits

Benefits are not guaranteed and vary by patient.

Improved energy or fatigue. Improved libido or sexual desire. Improved erectile function in selected patients. Improved mood, motivation, or sense of well-being. Improved muscle mass, strength, or body composition. Improved concentration or reduced brain fog.

5. Risks and Side Effects

Important: Testosterone is a prescription medication and may cause side effects. Some risks may require dose reduction, treatment pause, additional testing, specialist referral, urgent evaluation, or discontinuation.

Acne or oily skin. Hair loss or male-pattern baldness progression. Breast tenderness or gynecomastia. Mood changes, irritability, anxiety, or aggression. Insomnia or sleep changes. Fluid retention, swelling, or weight changes. Possible increase in blood pressure. Increased hematocrit/red blood cell count. Potential concern for blood clots in susceptible patients. Possible worsening of untreated sleep apnea. Possible worsening of urinary/prostate symptoms. Testicular shrinkage. Reduced sperm production and fertility risk. Injection site pain, bleeding, irritation, or infection. No guarantee of symptom improvement.

6. Fertility Consent

Fertility warning: TRT can reduce sperm production and may make it harder to have children. This effect may be reversible in some men but is not guaranteed.

Trying to Have Children Now?

May Want Children in Future?

Fertility Referral Discussed?

I understand TRT may reduce sperm production. I understand TRT may impair fertility. I understand alternatives/referral may be considered if fertility is important.

Fertility Notes

7. Contraindications and Conditions Requiring Caution

The patient should disclose all known conditions. Provider must clinically review before prescribing.

Known or suspected prostate cancer. Male breast cancer. Elevated PSA or abnormal prostate evaluation. High hematocrit/red blood cell count. Severe or untreated sleep apnea. Severe urinary/prostate symptoms. Recent heart attack or stroke. Uncontrolled heart failure. History of blood clots or clotting disorder. Uncontrolled hypertension. Significant liver or kidney disease. Controlled-substance misuse concern. None of the above disclosed by patient.

8. Monitoring and Follow-Up Requirements

I understand that TRT requires ongoing monitoring. This may include repeat testosterone levels, CBC/hematocrit, PSA when appropriate, blood pressure checks, CMP, estradiol if symptoms occur, and other labs based on my clinical situation.

I understand that my clinician may reduce my dose, hold therapy, stop therapy, or refer me to another clinician if safety concerns appear.

I understand that prescriptions may not be refilled if I do not complete required follow-up visits, labs, or safety monitoring.

I understand ongoing labs are required. I understand follow-up visits are required. I understand refills may be denied if monitoring is incomplete. I understand my dose may be changed for safety or response. I understand TRT may be stopped for safety concerns. I understand specialist referral may be needed.

9. Controlled-Substance and Medication Safety Agreement

Controlled medication: Testosterone is a controlled medication. Safe use, secure storage, and compliance with prescribing rules are required.

I will use testosterone only as prescribed. I will not share, sell, or transfer medication. I will store medication securely. I understand early refills may not be approved. I understand lost/stolen medication replacement is not guaranteed. I understand prescription monitoring history may be reviewed. I understand the clinic may require one prescriber/pharmacy for TRT. I understand misuse may lead to discontinuation. I agree to follow clinic refill policies.

10. Telemedicine Consent, If Applicable

I understand that telemedicine has limitations compared with an in-person exam. I may be asked to complete labs, provide vital signs, attend an in-person visit, or seek urgent/emergency care when appropriate.

I understand that controlled-substance prescribing by telemedicine must comply with applicable federal and state laws and clinic policy.

I understand telemedicine limitations. I will provide my accurate physical location during telemedicine visits. I understand in-person care may be required. I understand emergency/urgent care instructions. I understand controlled-substance telehealth rules apply. Not applicable / visit is in-person.

11. Patient Questions and Final Acknowledgment

Patient Had Opportunity to Ask Questions?

Patient Wants to Proceed?

Questions / Concerns / Additional Notes

I have read this consent or had it explained to me in a language I understand. My questions have been answered to my satisfaction. I understand the risks, benefits, alternatives, and monitoring requirements. I voluntarily consent to evaluation and treatment as clinically appropriate.

12. Patient Handwritten Signature

Patient may sign below using mouse, finger, or stylus.

Patient Printed Name

Signature Date

Signature Captured?

Patient signs inside the box above.

13. Provider Signature / Review

Provider Printed Name

Provider Signature Date

Provider Signature Captured?

Provider signs inside the box above.

Generated Consent Note

Use this as a chart summary. The signed/printed form should be retained according to clinic policy.

Click “Generate Consent Note” to review missing consent elements.