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Mammogram Waiver for Testosterone and/or Estradiol Pellet Therapy
I, _____________________________________, voluntarily choose to undergo implantation of subcutaneous bio-identical testosterone and/or estradiol pel et therapy, even though I am not current on my yearly mammogram. I understand that such therapy is controversial and that many doctors believe that estradiol replacement in my case is contraindicated. My Treating Provider has informed me it is possible that taking estradiol could possibly cause cancer, or stimulate existing breast cancer (including one that has not yet been detected). Accordingly, I am aware that breast cancer or other cancer could develop while on pel et therapy. For today’s appointment I DO NOT have a mammogram for the fol owing reason:
( ) My decision not to have one.
( ) Unable to provide the report at this time.
( ) My doctor’s decision not to have one. Please provide a note from your treating physician with their
rationale as to why they don’t want you to have a mammogram. I am aware that a current report must be sent by mail or faxed to our office prior to my next HRT appointment. The Treating Provider has discussed the importance and necessity of a mammogram since I receive testosterone and/or estradiol. __________ (initials of patient) I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was I understand that mammograms are the best single method for detection of early breast cancer. I understand that my refusal to submit to a mammogram test may result in cancer remaining undetected within my body. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or breast, uterine or cancer issues) that may be sustained by me in connection with my decision to not have a mammogram and undergo testosterone and/or estradiol pel et therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Dr. Donovitz, Treating Provider, BioTE Medical®, LLC., and any of their BioTE Medical® physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone and/or estradiol pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns ___________________________________________ _____________________________________________________ ______________________ Patient Print Name
Signature
Today’s Date
___________________________________________ _____________________________________________________ ______________________ Provider Print Name
Signature
Today’s Date

Source: http://www.fusionobgyn.com/wp-content/uploads/2012/11/Mammogram-Waiver.pdf

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