Testosterone Consent Form

Testosterone Pellet Consent

Patient Name ________________________ Date ______________

  •  I have been diagnosed with:
    Low testosterone level for medical conditionOther _______________________________
  •  I understand the condition and treatment options, including testosterone injections, testosterone patches, testosterone gels, testosterone pellet insertion, and not having any treatment .Risks/Benefits of Proposed Procedure:

The advantages of testosterone for men include:

a) behavioral changes such as decreased depression, anxiety, and irritability, increased energy and motivation, enhanced stamina, improved self-image and self-worth;

b) improvement in cognitive function and short-term memory; c) physical effects such as decreased body fat and increased lean body mass, muscle mass, and bone density;

d) sexual benefits such as increased libido and improved erectile function, and

e) multiple cardiovascular benefits. Just as there may be benefits to the procedure proposed, I also understand that medical and surgical procedures involve risks.

The risks of this procedure include: allergic reaction, bleeding, bruising or infection at the insertion site, blood clots, and the usual adverse side effects of testosterone (the possibility of increasing the growth rate of pre-existent prostate cancer. increased red cell count, acne, increased body hair and male pattern baldness, breast tenderness, edema, and elevation of liver function tests with rarely liver tumors, and suppress the development of sperm).

Complications; Unforeseen Conditions; Results:

I am aware that in the practice of medicine, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of this procedure.


The available alternatives and the likely result without such treatment have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.

Consent to Procedure(s) and Treatment:

Having read this form, my signature below acknowledges that: I voluntarily give my authorization and consent to the performance of the procedure described above.

Patient (or person authorized to sign for patient) __________________

Date __________________________________