Female New Patient Package
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- Matilda Roberts
- 5 years ago
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1 Female New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank you for your interest in BioTE Medical. In order to determine if you are a candidate for bio-identical testosterone pellets, 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 blood labs drawn at any Quest Diagnostics or LabCorp. 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. Your blood work panel MUST include the following tests: Estradiol FSH Testosterone Total TSH T4, Total T3, Free T.P.O. Thyroid Peroxidase CBC Complete Metabolic Panel Vitamin D, 25-Hydroxy (Optional) Vitamin B12 (Optional) Lipid Panel (Optional) (Must be a fasting blood draw to be accurate) Female Post Insertion Labs Needed at 4, 6 or 8 Weeks based on your practitioner s choice: FSH Testosterone Total CBC Lipid Panel (Optional) (Must be a fasting blood draw to be accurate) TSH, T4 Total, Free T3, TPO (Needed only if you ve been prescribed thyroid medication Estradiol New Female Patient Package Page Number: 1 Revision Date
2 Female Patient Questionnaire & History Name: (Last) (First) (Middle) Today s Date: Date of Birth: Age: Weight: Occupation: Home Address: City: State: Zip: Home Phone: Cell Phone: Work: Address: In Case of Emergency Contact: May we contact you via ? ( ) YES ( ) NO Relationship: Home Phone: Cell Phone: Work: Primary Care Physician s Name: Phone: Address: Marital Status (check one): Address City State Zip ( ) 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. ( ) My sex has suffered. ( ) I haven t been able to have an orgasm. Habits: ( ) I smoke cigarettes or cigars per day. ( ) I drink alcoholic beverages per week. ( ) I drink more than 10 alcoholic beverages a week. ( ) I use caffeine a day. New Female Patient Package Page Number: 2 Revision Date
3 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 all and when: Last menstrual period (estimate year if unknown): Other Pertinent Information: Preventative Medical Care: ( ) Medical/GYN exam in the last year. ( ) Mammogram in the last 12 months. ( ) Bone density in the last 12 months. ( ) Pelvic ultrasound in the last 12 months. High Risk Past Medical/Surgical History: ( ) Breast cancer. ( ) Uterine cancer. ( ) Ovarian cancer. ( ) Hysterectomy with removal of ovaries. ( ) Hysterectomy only. ( ) Oophorectomy removal of ovaries. Birth Control Method: ( ) Menopause. ( ) Hysterectomy. ( ) Tubal ligation. ( ) Birth control pills. ( ) Vasectomy. ( ) Other: Medical Illnesses: ( ) Polycystic Ovary Syndrome (PCOS) ( ) High blood pressure. ( ) Heart bypass. ( ) High cholesterol. ( ) Hypertension. ( ) Heart disease. ( ) Stroke and/or heart attack. ( ) Blood clot and/or a pulmonary emboli. ( ) Arrhythmia. ( ) Any form of Hepatitis or HIV. ( ) Lupus or other auto immune disease. ( ) Fibromyalgia. ( ) Trouble passing urine or take Flomax or Avodart. ( ) Chronic liver disease (hepatitis, fatty liver, cirrhosis). ( ) Diabetes. ( ) Thyroid disease. ( ) Arthritis. ( ) Depression/anxiety. ( ) Psychiatric disorder. ( ) Cancer (type): Year: New Female Patient Package Page Number: 3 Revision Date
4 Female Testosterone and/or Estradiol Pellet Insertion Consent Form Name: (Last) (First) (Middle) Today s Date: Bio-identical hormone pellets are hormones, biologically identical to the hormones you make in your own body prior to menopause. Estrogen and testosterone were made in your ovaries and adrenal gland prior to menopause. Bio-identical hormones have the same effects on your body as your own estrogen and testosterone did when you were younger, without the monthly fluctuations (ups and downs) of menstrual cycles. Bio-identical hormone pellets are plant derived and are FDA monitored, but not approved for female hormonal replacement. The pellet method of hormone replacement has been used in Europe and Canada for many years and by select OB/GYNs in the United States. You will have similar risks as you had prior to menopause, from the effects of estrogen and androgens, given as pellets. Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone is category X (will cause birth defects) and cannot be given to pregnant women. My birth control method is: (please circle) Abstinence Birth control pill Hysterectomy IUD Menopause Tubal ligation Vasectomy Other CONSENT FOR TREATMENT: I consent to the insertion of testosterone and/or estradiol pellets in my hip. I have been informed that I may experience any of the complications to this procedure as described below. These side effects are similar to those related to traditional testosterone and/or estrogen replacement. Surgical risks are the same as for any minor medical procedure and are included in the list of overall risks below: Bleeding, bruising, swelling, infection and pain; reaction to local anesthetic and/or preservatives; extrusion of pellets; hyper sexuality (overactive Libido); lack of effect (from lack of absorption); breast tenderness and swelling especially in the first three weeks (estrogen pellets only); increase in hair growth on the face, similar to pre-menopausal patterns; water retention (estrogen only); increased growth of estrogen dependent tumors (endometrial cancer, breast cancer); birth defects in babies exposed to testosterone during their gestation; growth of liver tumors, if already present; change in voice (which is reversible); clitoral enlargement (which is reversible). The estradiol dosage that I may receive can aggravate fibroids or polyps, if they exist, and can cause bleeding. 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 annually. This condition can be reversed simply by donating blood periodically. 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; decreased weight; decrease in risk or severity of diabetes; decreased risk of heart disease; decreased risk of Alzheimer s and dementia. I have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone and or estrogen 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 pellets under my skin. This consent is ongoing for this and all future pellet insertions. 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 pellet 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 contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal. Print Name Signature Today s Date New Female Patient Package Page Number: 4 Revision Date
5 BHRT Checklist For Women Name: Date: Symptom (please check mark) Never Mild Moderate Severe Depressive mood Memory Loss Mental confusion Decreased sex drive/libido Sleep problems Mood changes/irritability Tension Migraine/severe headaches Difficult to climax sexually Bloating Weight gain Breast tenderness Vaginal dryness Hot flashes Night sweats Dry and wrinkled skin Hair falling out Cold all the time Swelling all over the body Joint pain Family History Heart Disease Diabetes Osteoporosis Alzheimer s Disease Breast Cancer NO YES New Female Patient Package Page Number: 5 Revision Date
6 Hormone Replacement Fee Acknowledgment Although more insurance companies are reimbursing patients for the BioTE Medical Hormone Replacement Therapy, there is no guarantee. You will be responsible for payment in full at the time of your procedure. All claims must be filed as OUT OF NETWORK, since BioTE is not credentialed with any insurance company. We will give you paperwork to send to your insurance company to file for reimbursement upon request. New Patient Consult Fee $ Female Hormone Pellet Insertion Fee +$ You will pay for first procedure: $ Subsequent procedures will be $ (Approximately every 3 to 5 months) WE DO NOT FILE INSURANCE ON THIS PROCEDURE AND IT IS OUT OF NETWORK We accept the following forms of payment: Master Card, Visa, Discover, American Express, Personal Checks, Care Credit and Cash. You can also prepay over a period of months. INSURANCE DISCLAIMER 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. GTFCC Health & Wellness Tax ID# 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 will provide a form to send to your insurance company and a receipt showing that you paid out of pocket for out of network services. 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 follow 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. We do not pre-certify or obtain preauthorization for this service since it is an out of network service. 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. By signing this document, you are agreeing with the terms of this service and understand it is an out of network procedure. Print Name Signature Today s Date New Female Patient Package Page Number: 6 Revision Date
Female Patient Questionnaire & History
Female Patient Questionnaire & History Name: Today s Date: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: E-Mail Address: May we contact you via E-Mail? ( ) YES
Patient Information. Primary Care Physician: Last Name: First Name: MI: Address: City/ST/Zip code: Home Phone :( ) Cell Phone: ( ) Leave Message
Patient Information Last Name: First Name: MI: Address: City/ST/Zip code: Home Phone :( ) Leave Message Cell Phone: ( ) Leave Message Work Phone: ( ) ext: Date of Birth (mm/dd/yyyy): / / Sex: Male Ο Female
Patient Information Sheet. Spouse Information. Emergency Contact Information. Referral. Insurance Information
Patient Information Sheet Patient of Birth Patient Social Security # Street Address City, State & Zip code Home Phone Cell Phone Work Phone Email Address Pharmacy Address/Phone: Patient Employer Address
Patient Information. Primary Care Physician: Last Name: First Name: MI: Address: City/ST/Zip code: Home Phone :( ) Cell Phone: ( ) Leave Message
Patient Information Last Name: First Name: MI: Address: City/ST/Zip code: Primary Insurance: Policyholder: DOB: / / SSN: Group ID #: Individual ID #: Home Phone :( ) Leave Message Cell Phone: ( ) Leave
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