• I have disclosed accurate and true information regarding my medical history, medication history and surgeries. I understand that bio-identical hormone estrogen and/or testosterone replacement pellet insertion is a minor surgical procedure. I consent to this procedure. The procedure has been explained to me. I understand that as with any surgical procedure there are risks to the patient and no treatment or procedure is ever deemed 100% safe. I understand that the following are rare but a possibility as a result of this procedure:
  • Acne Growth of preexisting estrogen dependent tumors
    Area infection Increased facial hair growth
    Area Swelling Loss of hair on scalp
    Bleeding Minor discomfort/pain
    Bruising/ Soreness Minor or slight scarring at the incision site
    Deepening of voice Pellet extrusion
    Discoloration of the skin
  • I understand that once the pellet(s) have been inserted they cannot be removed. I understand that it takes most patients approximately 24 to 72 hours after the pellet insertion for the hormones to become active in the patient’s system. I agree to follow the written post-surgery instructions I am given. I understand that if I am not menopausal, I will continue a reliable birth control method. I understand that in addition to pellet therapy, I may require additional medication such as sublingual or oral progesterone.
  • I understand, and agree, to immediately contact the Heal n Cure staff at (847) 686-4444 if I experience partial or full pellet extrusion (exiting the body), excessive area pain, excessive bleeding and/or wound infection. I also agree that if I fail to report the previously mentioned situations that I will not hold Meena Malhotra M.D. liable for any negative physical, emotional or mental outcome. Either Dr. Malhotra, or a staff member, has explained and reviewed alternative methods of hormone replacement, and I understand that I have options. I request that the procedure be performed today
  • Make sure you enter this Email correctly as we will be sending you a filled PDF form to this Email Id to get Witness Signature on it.