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Sheila L. Uridil, MSN, APRN, AGACNP-BC, ANP-BC
Joseph E. Uridil IV, MSN, APRN, AGACNP-BC
NeighborhoodHealthcareJ.S@gmail.com

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Patient Evaluation, Informed Consent, Waiver, and Treatment Agreement

Testosterone replacement therapy (TRT) is indicated for symptomatic hypogonadism with consistently low morning testosterone and must be individualized based on symptoms, comorbidities, and patient preferences. TRT improves sexual function, mood, bone density, and muscle mass, but does not clearly reduce cardiovascular events and may increase erythrocytosis and prostate-related events, so careful monitoring is essential. Contraindications include prostate or breast cancer, severe untreated sleep apnea, uncontrolled heart failure, and erythrocytosis; in men with fertility goals, use gonadotropins or SERMs instead which are not provided by Neighborhood Healthcare. Shared decision-making and regular follow-up are critical to balance benefits and risks.

SECTION 1 – MEDICAL EVALUATION

Symptoms of Possible Testosterone Deficiency (Check all that apply)*
<strong>Symptoms of Possible Testosterone Deficiency</strong> (Check all that apply)
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Medical History (Check all that apply)*
<strong>Medical History</strong> (Check all that apply)
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Allergies*
<strong>Allergies</strong>
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Laboratory Evaluation (Baseline Required)*
<strong>Laboratory Evaluation (Baseline Required)</strong>
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SECTION 2 – INFORMED CONSENT

I understand that Testosterone Replacement Therapy (TRT) is used to treat clinically significant hypogonadism and symptoms associated with testosterone deficiency.

Potential Benefits

  • Improved energy and vitality
  • Improved libido and sexual performance
  • Increased lean muscle mass
  • Improved mood and mental clarity
  • Improved bone density
  • Metabolic improvement in some patients

Potential Risks & Side Effects

  • Elevated hematocrit (polycythemia)
  • Blood clots
  • Fluid retention
  • Acne or oily skin
  • Mood changes
  • Worsening sleep apnea
  • Gynecomastia
  • Infertility and suppression of natural testosterone production
  • Testicular atrophy
  • PSA elevation or prostate enlargement
  • Uncertain long-term cardiovascular risk

I understand long-term safety data is still evolving.

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SECTION 3 – MONITORING REQUIREMENTS

Ongoing monitoring is required and may include:

  • Testosterone laboratory testing at 1 month, 3 months, & 6 months initially; then every 6-12 months thereafter
  • CBC monitoring for elevated hematocrit
  • PSA monitoring when appropriate
  • Dose adjustments based on labs and symptoms

Failure to comply may result in discontinuation of therapy.

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SECTION 4 – FINANCIAL POLICY & PAYMENT AGREEMENT

TRT services are provided on a cash-pay basis. The patient is financially responsible for all services rendered.  All medications and administration materials are included, but required laboratory expenses are the responsibility of the patient.

Initial Evaluation Fee: $150 (Non-refundable)

Monthly Membership Fee: $150 for first 6 months, $100 monthly thereafter.

Failure to complete required labs or maintain payment may result in suspension of treatment. Outstanding balances may be sent to collections as permitted by Arizona law.

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SECTION 5 – WAIVER & LIMITATION OF LIABILITY

I acknowledge that I have disclosed my medical history, understand the risks and financial obligations, and voluntarily consent to treatment. I release Neighborhood Healthcare, Sheila L. Uridil, AGACNP-BC, ANP-BC, and Joseph E. Uridil IV, AGACNP-BC from liability except in cases of gross negligence or willful misconduct.

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