Linda Lea, APRN-CNP, PLLC 4771 NW 122 nd Street, Suite C Oklahoma City, Oklahoma, Office: Fax:

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1 4771 NW 122 nd Street, Suite C FEMALE NEW PATIENT PELLET PACKET Please carefully read and complete the contents of this package so we can be ready for your appointment to regain optimal hormone balance. The first appointment includes a physical examination, review medical history, and laboratory tests will be ordered. Self pay labs are sometimes drawn in the office but frequent a requisition form and a list of the lab draws sites will be provided. Insurance sometimes cover the pre-insertion laboratory tests. Your test results will be faxed to the Linda Lea Clinic and will be reviewed by Linda. Another scheduled appointment for the pellet insertion is needed and a copy of the lab will be provided. Post insertion labs will be draw 4 weeks after pellet insertion. After the dose of testosterone is established, labs will be drawn once or twice yearly along with a consultation, if needed. If we meet challenges along the way additional appointments will be schedule for complicated cases. If you have had testosterone pellets in the past, it is your responsibility to bring a copy of the office note which will include dose of testosterone implanted at your last insertion. Optimal results are always accompanied by regular exercise, weight management, a healthy diet, adequate sleep, and manageable stress. Testing and balancing other hormones such as, thyroid, DHEA, melatonin and assuring healthy functioning adrenal glands will enhance overall well being and longevity. Should you be interested in these areas of health, they can be managed at the Linda Lea Clinic. Female Pre Insertion Labs LIPID PANEL (must be fasting blood draw to be accurate) FASTING BLOOD SUGAR ESTRADIOL TESTOSTERONE TOTAL PROGESTERONE TSH FREE T3 FREE T4 TPO (thyroid peroxidase) FSH CBC COMPLETE METABOLIC PANEL B12 (optional) D3 (optional) Female Post Insertion lab needed at 4 weeks FSH Testosterone Total Estradiol (optional) CBC

2 4771 NW 122 nd Street, Suite C PATIENT PROFILE PLEASE PRINT CLEARLY NAME: TODAY S DATE First Last Middle DATE OF BIRTH: AGE: OCCUPATION: May we contact you by ? Address: How did you hear about us? Home Street Address: City: State: Zip: Home Phone: Cell Phone: Work: Emergency Contact: Relationship: Primary Care Provider: Phone: Marital Status (check one): ( )Married ( )Divorced ( )Widow ( ) Living with Partner ( )Single Height: Weight: Desired Weight: Are you presently Dieting? Which Diet? Current Medications: Supplements: Exercise: ( ) I don t exercise ( ) I exercise every day for minutes ( )I exercise 3 times a week ( )I lift weights times a week ( )Normal daily activity is what I consider exercise ( )I have a physical job so I don t exercise in addition Surgical History: Y / N In the event we cannot contact you by the mean s you have provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment or scheduled appointment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment. Name: Relationship: Home Phone: Cell Phone: Work:

3 4771 NW 122 nd Street, Suite C Any known drug allergies: Current Hormone Replacement Therapy: Past Hormone Replacement Therapy: Last Menstrual Period: Other Pertinent information: o I eat anything I want o I don t eat much but gain weight o Social History ( ) I am sexually active ( ) I want to be sexually active ( ) I have completed my family ( ) I am married ( ) I have a partner ( ) I have permanent birth control ( ) I am menopausal Habits ( ) I smoke cigarettes or cigars per day. ( ) I smoke a vape hours per day. ( ) I drink alcoholic beverages per week. ( ) I drink more than 10 alcoholic beverages a week. ( ) I use caffeine a day. ( ) I am a recovering alcoholic Family History ( ) Breast Cancer ( ) Ovarian Cancer ( ) Colon Cancer ( ) Heart Disease ( ) Lung Disease ( ) Prostate Cancer ( ) Diabetes ( ) Hypertension ( ) Stroke ( ) Blood Clots ( ) Thyroid Disease OTHER: Check all that apply ( )Thinning hair ( )Palpitations ( )PMS ( )Weight Gain ( )Night Sweats ( )Mood Swings ( )Shingles ( )Erectile Dysfunction ( )Restless leg Syndrome ( )Aches and Pains ( )Jaundice ( )Dry Skin ( )Acne ( )Lack of Motivation ( )Hyperpigmentation on face ( )Ovarian Cysts ( ) Low Lidibo OTHER: Medical Illnesses ( )High blood pressure ( )Heart bypass ( )High cholesterol ( )Hypertension ( )Heart disease ( ) Stroke or heart attack ( )Blood clotting disorder or ever had a blood clot ( )Arrhythmia ( )Fibromyalgia ( )Any form of Hepatitis ( )Diabetes ( )Lupus or other autoimmune disease ( )Chronic liver disease ( )Thyroid disease ( )Arthritis ( )Depression/anxiety ( )Psychiatric disorder: ( )Cancer (type) Year: ( ) Sleep Apnea ( )Adrenal Fatigue ( )Hypoglycemia ( )ADD/ADHD ( )High Cholesterol ( )COPD ( )Insulin Resistance ( )Asthma ( )Osteoporosis/osteopenia ( )Anemia ( )Low Blood Pressure ( )PCOS ( )Chronic Diesase ( )Chronic Fatigue ( )Addisons or Cusings Disease ( )Schizophrenia ( )Bipolar or mania ( )Pacemaker ( )Glaucoma ( )Restless Leg ( )Multiple Sclerosis

4 ZEG BERLIN - Center of Epidemiology and Health Research

5 4117 NW 122 nd Street, Suite C BIO-IDENTICAL HORMONAL THERAPY FEMALE TESTOSTERONE HORMONE PELLET INSERTION CONSET FORM Although this therapy has been approved for human use, there are few providers who currently administer estradiol and testosterone pellets in the United States. I realize that this is not the usual and customary means of hormone replacement. Estrogen and testosterone were made in your ovaries and adrenal gland prior to menopause. Bioidentical hormones have the same effects on your body as your own estrogen and testosterone did when you were younger, without the monthly fluctuations (ups and downs) of menstrual cycles. Bioidentical hormone pellets are made from plants and are FDA monitored but not approved for female testosterone replacement. The pellet method of hormone replacement has been used in Europe, Canada and United States since Studies done in Canada and Europe find pellet therapy to be safer than traditional oral hormone therapy. Worth Noting: The WHI study on hormone replacement therapy that was reported first in 2002 had many flaws in the study (only studied Premarin {horse estrogen} and Provera {a synthetic type of progestin}) and had findings that are not consistent with the last 1,500 studies done on hormone replacement therapy. The WHI study is not applicable to treatment with bioidentical hormone replacement with pellets. I realize in the past male and female athletes have abused testosterone. When they took large quantities of synthetic testosterone, they may have incurred heart problems, elevated cholesterol, and other health problems. However, low dose, non-oral, natural testosterone that is used in bio-identical hormonal therapy has NOT been associated with these problems. Patients who are not sterilized and not menopausal are advised to continue reliable birth control while participating in pellet hormonal replacement therapy. Testosterone is category X (will cause birth defects) and cannot be given to pregnant women. YOU MUST BE STERILIZED OR USE EFFECTIVE BIRTH CONTROL TO USE HORMONAL PELLETS! My birth control method is: (please circle) o Abstinence Birth o control pill o Hysterectomy o IUD o Menopause o Tubal ligation o Vasectomy o Other CONSENT FOR TREATMENT: I consent to the insertion of testosterone pellets in my hip. I have been informed that I may experience any of the complications to this procedure as described below. Surgical risks are the same as for any minor medical procedure and are included in the list of overall risks: Bleeding, bruising, swelling, infection and pain at the insertion site Lack of effect (from lack of absorption) Thinning hair, male pattern baldness Increase in hair growth on the face Blood clots (phlebitis) Growth of liver tumors, if already present Change in voice Expulsion of pellets Hyper sexuality (overactive Libido) Acne Mood swings Birth defects in babies exposed to testosterone during their gestation Change in voice (which is reversible) Clitoral enlargement (which is reversible)

6 4117 NW 122 nd Street, Suite C Benefits that have been explained to me include: Increased libido, energy, and sense of well-being Decreased frequency and severity of hormonal migraine headaches Decrease in mood swings, anxiety & irritability (secondary to hormonal decreases) Increase in muscle mass and decrease in subcutaneous fat (cellulite) Improvement in balance Decreased central obesity Improved dry eyes Possible improvement in arthritis and fibromyalgia As this procedure is often an expense not covered by insurance benefits, I understand payment is due in full at the time of service. After the initial bio-identical hormonal therapy insertion, I understand my insurance will be not billed. I agree to immediately report to the Linda Lea Clinic any adverse reaction or problems that might be related to my therapy. Potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of bio-identical and other treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefits from the administration of bio-identical testosterone therapy. I accept these risks and benefits and I consent to the insertion of testosterone pellets under my skin. My questions have been answered to my satisfaction. By signing below I acknowledge that there may be risks of testosterone therapy that we do not yet know, at this time, and I accept those and all the above risks by accepting therapy and signing below. This consent is ongoing for this and all future pellet insertions. Print Name Signature Date

7 4771 NW 122 nd Street, Suite C NO-SHOW AND CANCELLATION POLICY Appointment times are scheduled to allow us to provide individualized care to each patient during the appointment time. In an effort to contain our fees and promote efficient access to our clinic, we require that any appointment that is no longer needed or unable to be kept much be cancelled more than 24 hours in advance. Cancellation must be made by telephone by speaking to our scheduler. Patients will not be charged or an office visit if the cancellation is made the day before the appointment (24 hours). In the event an appointment is missed or cancelled with less than 24 hours notice, a $35 charge will be billed. If a second, no-show or same day cancellation occurs, we reserve the right to terminate the patient-clinic relationship. This policy is in effect at our office including clinical and cosmetic appointments. Lastly, we advise you to review this agreement with the counsel of your choosing and by signing this agreement you acknowledge that you have had an opportunity to review this agreement with counsel of your choice if you desire to do so. This agreement shall be valid and enforceable for five years from the Linda Lea Clinic s last date of service to you. The Linda Lea Clinic reserves the right to modify and policies without notice. My signature below indicates that I have read and understand these policies. Patient or Responsible Party Signature Today s Date Please Print Name

8 4117 NW 122 nd Street, Suite C Accepted Insurances: Assurant Aetna Cigna Mutual Of Omaha PCHS Savility MultiPlan/ValuePoint United Health Care Geha EPO Plan First Health Coventry Tricare Medicare Health Choice Humana Pacifcare AARP Secure Horizons BCBS Exclusions: Blue Links, Blue Advantage & Preferred Plans

9 4117 NW 122 nd Street, Suite C Hormone Replacement Fee Schedule Acknowledgment NO MONTHLY FEES! New Patient Consult Fee (with insurance): Your Office Visit Copay (Varies Upon Policies) New Patient Consult Fee (without insurance): 30 minutes: $ minutes: $50.00 Female Pellet Insertion Fee: $ Pellets: (most women need 1-2 pellets) Male Pellet Insertion Fee: $ Pellets: $35.00 per pellet (most men need 5-8 pellets) Pellets with anastrozole $40.00 per pellet Pre Pelleting Lab Panel: Call for pricing Post Pelleting Lab Panel (without insurance): Call for pricing o All fees are expected at the time of service. o We do not have billing or pre-certification staff. All contact with insurance companies is your responsibility. o Telephone and mail will be used for most patient communication, unless otherwise discussed. o Preventative bio-identical pellet replacement is considered a form of alternative medicine; therefore, insurance does not recognize it as a medical necessary. Most insurance companies will not reimburse for pellet implantation. o This service is not covered by Medicare so you may NOT send in your bill for reimbursement. o Payment is due at the time of service. We accept cash, check, Visa, MasterCard and Discover. Print Name Signature Date