Liability Waiver

The goal of this consent form is to review the potential risks and benefits associated with the use of testosterone hormone therapy.

A. The full medical effects and safety of hormone therapy are not fully known.

Potential adverse effects may include, but are not limited to:

  • Increased cholesterol and/or fats in the blood, which may increase the risk for heart attack or stroke
  • Increased number of red blood cells (increased hemoglobin) which may cause headache, dizziness, heart attack, confusion, visual disturbances, or stroke
  • Acne
  • Polycythemia
  • Hepatotoxicity
  • Immunostimulatory and Immunosuppressive
  • Hair Loss
  • Stunted Growth in Pre-Pubescent Juveniles
  • Edema
  • Gynecomastia
  • Prostate Enlargement
  • Testicular Atrophy
  • Increased risk of the following: Heart disease and stroke
  • High blood pressure
  • Liver inflammation
  • Increased or decreased sex drive and sexual functioning
  • Worsening of sleep apnea

B. The risks for some of the above adverse events may be INCREASED by

  • Pre-existing medical conditions
  • Pre-existing psychiatric conditions
  • Cigarette smoking
  • Alcohol use

C. Irreversible body changes (potential increases with length of time on hormones) resulting from hormone therapy may include, but are not limited to:

  • Deepening of voice
  • Development of facial & body hair
  • Fat redistribution
  • Genital changes (i.e. enlargement of clitoris & labia, vaginal dryness)
  • Increased bone density
  • Infertility while using testosterone
  • Male pattern baldness

My signature below constitutes my acknowledgment of the following:

I have read and understood the above information regarding hormone therapy, and accept the risks involved.

I believe I have adequate knowledge on which to base an informed consent to the provision of hormone therapy I authorize and give my informed consent to the provision of hormone therapy.