918.392.8606 (Medical Spa)
918.995.8909 (Emerge Spa & Salon at River Spirit Casino Resort)

 

 

 

 

Emerge Medical & Well Spa Female New Patient Form

Fields marked with an * are required

Female New Patient Form

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. We look forward to partnering with you to help you feel your best again.

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  FASTING blood  lab  drawn  at  any  Quest Laboratory/ or LabCorp Lab. 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. Please fast for 12 hours prior to your blood draw.

Your fasting 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)

Female Post Insertion Labs Needed at 4, 6 or 8 Weeks based on your practitioner’s choice:

FSH

Testosterone Total

CBC



MEDICAL HISTORY


SYMPTOMS


Allergy History Questionnaire


Wellness Consent

Financial Information

PLEASE HAVE INSURANCE CARDS READY FOR THE CONCIERGE TO COPY

Some medical procedures are not covered by insurance plans. Full payment is expected by the day of your initial treatment. For services that are covered by insurance, all patients are responsible for their insurance deductible, co-pay and co-insurance amounts due. Even after pre-authorization or pre-determination, some insurance companies may not pay the full fee for some services and may not cover some services at all. If your insurance company determines that the procedure is not covered for any reason, you will be responsible for the remaining charge not paid by your insurance.


Female Testosterone and/or Estradiol Pellet Insertion Consent Form

Bio-identical hormone pellets are concentrated 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 made from yam 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 cannot be given to pregnant women.


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.

Side effects may include: Bleeding, bruising, swelling, infection and pain; 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); safety of any of these hormones during pregnancy cannot be guaranteed. Notify your provider if you are pregnant, suspect that you are pregnant or are planning to become pregnant during this therapy, continuous exposure to testosterone during pregnancy may cause genital ambiguity; 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 and 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 agree to immediately report to my practitioner’s office any adverse reaction or problems that might be related to my therapy. Potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of bio-identical and other treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefits from the administration of bio-identical therapy. 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 insertions.

I understand that payment is due in full at the time of service. 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.