Hormone Therapy Informed Consent Form
This form is designed to provide you with information about hormone therapy and obtain your consent for treatment.
Patient's Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I understand that hormone therapy may involve the following:
Potential Benefits of Hormone Therapy:
Please check all that apply.
Benefits
*
Reduction of gender dysphoria
Development of secondary sexual characteristics
Improved mood and well-being
Increased energy levels
Other (please specify)
Potential Risks of Hormone Therapy:
Please check all that apply.
Risks
Blood clots
Cardiovascular issues
Hormonal imbalances
Mood swings
Infertility
Other (please specify)
I have discussed the risks and benefits of hormone therapy with my healthcare provider, and I have had the opportunity to ask questions.
*
Yes
No
I consent to hormone therapy treatment as discussed with my healthcare provider.
*
Yes
No
Patient Signature
Date of Signature
-
Month
-
Day
Year
Date
Submit
Should be Empty: