Although Testosterone Replacement Therapy (“TRT”) has been utilized safely and effectively, it is necessary to discuss potential risks. You should also be aware of the alternatives to TRT, including not receiving the treatment. It is important that you consider the information we have provided you. Be sure that you are doing what is right for you. If you are unsure, then perhaps you should take some time to weigh your options or consult another health care provider.

Please review the following items, which discuss informed consent. Your clinical provider will attempt to answer all of your questions to your satisfaction. Initial below each statement that you have read, understand, and agree with:

1. This is my consent for Justin Kitchens F.N.P. (“MedFit of GA”), including any clinical provider who works with MedFit of GA, to begin treatment for TRT in pellet, injection or gel form.

2. It has been explained to me, and I fully understand, that occasionally there are complications with this treatment such as gynecomastia, acne, fat loss, and increased estrogens.

3. I understand I may retain extra fluid in the body – This can cause problems for patients with heart, kidney, or liver disease.

4. TRT may cause your LH and FSH levels to be severely limited, affecting your fertility. Patients should not be on TRT if attempting to father a child.

5. I have been informed that Testosterone may lead to liver inflammation and damage. I have been informed that I will be monitored for liver problems before starting TRT and periodically during therapy.

6. TRT may cause changes in cholesterol levels, red blood cell levels, PSA levels, liver function enzymes, and other hormone levels which will be monitored with periodic blood tests.

7. I understand it is my responsibility to be aware of the above complications and let my clinical provider know when I have a concern.

8. I understand that I will have periodic blood tests to monitor my blood levels.

9. I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse.

10. I have provided my clinical provider with my complete past medical and health history. I have had an opportunity to discuss with my clinical provider my complete past medical and health history. All of my questions concerning the risks, benefits, and alternatives have been answered. I am satisfied with the answers.

11. I agree that TRT works best when I change lifestyle habits such as limiting alcohol, stopping smoking, exercising, and eating correctly.

All of my questions and concerns regarding treatment have been answered to my satisfaction. I further acknowledge that the risks and benefits of this treatment have been explained to me. I am of sound mind, under no undue influence and am competent to make this decision and do so of my own free will. I have no further questions.I consent to taking Testosterone as proposed by my clinical provider. I have complete understanding of and agree to follow the terms of this Informed Consent. A copy of this document has been given to me.