I UNDERSTAND THAT BLOOD TESTS AND MEDICAL HISTORY WILL BE USED TO ESTABLISH MY BASELINE HORMONE STATUS.  I AGREE TO FOLLOW ALL RESONABLE REQUESTS FOR ONGOING LAB TESTING TO ENABLE FEMME CLINIQUE PHYSICIANS TO TREAT ME EFFECTIVELY.  IN ADDITION, I WILL REPORT ANY POTENTIAL ADVERSE REACTIONS OR CHANGES IN MY MEDICATIONS OR DOSING TO FEMME CLINIQUE SO THEY CAN HELP ME OPTIMIZE MY TREATMENT BENEFITS AND PREVENT ANY SIDE-EFFECTS AND AS WITH ANY THERAPY I UNDERSTAND THERE ARE POTENTIAL SIDE EFFECTS ALTHOUGH THEY TEND TO BE MINIMAL.  POTENTIAL SIDE EFFECTS INCLUDE MOOD CHANGES, ACNE, HAIR LOSS/GROWTH, BREAST TENDERNESS, AND ABNORMAL MENSES. I UNDERSTAD THAT MY TREATMENT IS DESIGNED TO MINIMIZE ANY OF THESE SIDE EFFECTS AND INCREASE BENEFITS OF THE THERAPY.  I AGREE TO COMPLY WITH THE RECOMMENDED DOSES TO HELP PREVENT ANY COMPLICATIONS.

I UNDERSTAND THAT I WILL BE IN CHARGE OF ADMINISTERING MY HORMONES AND SUPPLEMENTS AS PART OF MY TREATMENT AND I UNDERSTAND FEMME CLINIQUE CANNOT BE HELD RESPONSIBLE FOR MY MISUSE OF ANY MEDICATIONS.  I UNDERSTAND THAT FEMME CLINIQUE IS MANAGING ONLY MY CARE IN RESPECT TO HORMONE THERAPY AND AGREE TO HAVE A PRIMARY CARE PROVIDER FOR OTHER HEALTH ISSUES UNLESS OTHERWISE EXPLICITLY AGREED UPON BY BOTH PARTIES.  I UNDERSTAND THAT FEMME CLINIQUE WILL BE AN ADDITION TO MY MEDICAL CARE BUT NOT A REPLACEMENT FOR MY PRIMARY MEDICAL PROVIDER.  I AGREE TO RECEIVE YEARLY MAMMOGRAMS AND PAP SMEARS AND REPORT ANY ABNORMAL RESULTS TO MY PHYSICIAN AT FEMME CLINIQUE.

I UNDERSTAND THAT I HAVE THE RIGHT TO CHOOSE ANY PHARMACY FOR FILLING MY PRESCRIPTION FROM FEMME CLINIQUE.  

If you have read the above statements and understand them, please sign and date: