Hormone Therapies | Beacon, NY | Pro-Health & Wellness

Serving Dutchess, Putnam, Orange and Westchester Counties

Phillipstown Plaza

3182 Route 9 Suite 209 Cold Spring NY 10516

530 ROUTE 6, SUITE 1 MAHOPAC, NY 10541

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(845) 907-3003

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Men & Women’s Informed Consent to Treat

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I hereby give my consent to evaluation and treatment by (Pro-Health & Wellness), Casandra

Way FNP-BC, and any other provider associated with (Pro-Health & Wellness) for the following

specified condition(s):

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Andropause or associated symptoms (Including testosterone replacement, manipulating hormone levels including DHEA and estradiol).

Growth hormone abnormalities including decreased or suboptimal IGF -1, decreased or suboptimal Vitamin D-3 levels.

Nutritional deficiencies, Overweight/Obesity, B12 injections and anything else the medical provider deems is necessary.

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I acknowledge that treatment with testosterone, growth hormone stimulators, bioidentical hormone replacement therapy, B12, and thyroid optimization are considered off label use of the associated medications and have not been FDA approved for the use of health optimization, wellness, weight loss and/or for anti-aging purposes unless there is true medical necessity.

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I agree to the administration of hormone replacement therapy, and/or nutritional supplements,

and/or drugs designed to alter hormone levels which will meet my specific treatment objectives

and to treat any specific diagnoses I might have.

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