Balanced: Women’s Hormones and Weight loss LLC Clinical Policies
PATIENT CONSENT FOR HORMONE RESTORATION AND TREATMENT WITH Balanced: Women’s Hormones and Weight loss LLC.
If you have any questions, please feel free to ask us. Please initial each point acknowledging you understand that:
_______ If you are late or miss your appointment, you may be subject to a $50 fee or full appointment charge.
________Services must be paid for by the time of service.
________Health insurance typically does not cover services provided at Balanced: Women’s Hormones and Weight loss LLC.
________Testosterone is considered a controlled substance. I agree that I will take my medications as prescribed. I agree to follow my medical provider’s instructions. I also agree that I will not sell or share my prescriptions to other individuals.
________I understand that treatments used at Balanced: Women’s Hormones and Weight loss LLC might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional and supplemental counseling, and possibly weight loss treatment.
_______ I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department.
________I acknowledge that Balanced: Women’s Hormones and Weight loss LLC and Brigit Rauterkus APRN are not my primary care provider. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed at Balanced: Women’s Hormones and Weight loss LLC.
________I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation.
________I understand that having an appointment with Balanced: Women’s Hormones and Weight loss LLC does not necessarily entitle me to being issued a prescription for hormone replacement or additional medications. Every individual is different, and it is at the medical providers’ discretion to issue a prescription.
________I understand that I must maintain my follow up appointments to remain on treatment. It is important that lab work is monitored regularly for safety purposes. It is important that Brigit Rauterkus APRN manages my treatment, and it is at their discretion to provide
________I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.
________I am voluntarily requesting treatment with Balanced: Women’s Hormones and Weight loss LLC and Brigit Rauterkus APRN in regard to hormone replacement therapy and additional treatment modalities as determined by a mutual decision between myself and the medical provider even if my hormone levels are considered to be in normal range for my age based off of other medical society recommendations and guidelines.
________I do not hold any medical practitioner of Balanced: Women’s Hormones and Weight loss LLC responsible for performing breast/ovarian/cervical/uterine cancer screening, colon cancer screening, PAP smears, pelvic exams, mammograms, or other age-related preventive care. I agree that I will follow up with my primary care provider and/or OB/GYN to obtain these screenings and I hold Balanced: Women’s Hormones and Weight loss LLC and Brigit Rauterkus APRN harmless if an adverse event occurs during my treatment. I will ensure that my primary care provider and/or OB/GYN provides the results of such screenings to Balanced: Women’s Hormones and Weight loss LLC as this could change the treatment prescribed to me.
We use cookies to analyze website traffic and optimize your website experience. By accepting our use of cookies, your data will be aggregated with all other user data.