It is important that you understand the risks and benefits associated with Testosterone Replacement Therapy (TRT) before beginning or continuing treatment. TRT is not a new area of medicine and is used for the treatment of a medical condition known as hypogonadism in males. It is important that you consider the information provided and discuss it carefully with your provider. Be sure that you are doing what is right for you. If you are unsure, then you should refuse and/or discontinue treatment.

The medications that may be prescribed as part of your treatment may include Testosterone, HCG, Anastrozole, Clomiphene, as well as Vitamin D, B12, and other dietary supplements, where indicated. Recommended treatment in some instances may include "off-label" drug use of an FDA-approved medication. Testosterone is FDA-approved only for use in men who lack or have low testosterone levels in conjunction with associated symptoms. These symptoms are often related to male andropause or aging and may include decreases in energy and motivation, poor concentration or memory, feelings of depression or irritability, sleep disturbances, reduced muscle mass, increased body fat, and reduced sexual desire or libido.

These symptoms may be treatable in hypogonadal males utilizing testosterone. The therapeutic objective of TRT is to restore normal testosterone levels, helping to reduce these symptoms. There are a number of potential side effects related to TRT. You should discuss each of these with your medical provider. Side effects may include:
- Increased red blood cells
- Acne
- Sleep apnea
- Breast enlargement
- Testicular atrophy
- Lowered sperm count
- Mood swings
- Injection site reactions such as bleeding, pain, swelling, redness, or infection
- Increased estrogen production
- Fluid retention

TRT is not recommended for patients who have breast or prostate cancer. You should also be aware that some recent studies have associated TRT with increased risk for adverse cardiovascular events, such as blood clots, heart attacks, or strokes, in certain types of patients. If you have a history of cardiac or urologic problems, your provider may require clearance from your cardiologist or urologist prior to initiating treatment. Each patient's own risks can vary depending upon health history and lifestyle. It is important that you provide an accurate and complete medical history to your provider.

Patient Consent:
I have read and understand that there may be complications arising from or related to treatment as described above and explained by my treating medical provider. I have had an opportunity to discuss my complete past medical and health history, including any serious problems and/or injuries, as well as my family history of diseases and conditions, with my provider. All of my questions concerning the risks, benefits, and alternatives to treatment have been answered. I am satisfied with the answers and desire to commence treatment, knowing the risks and potential side effects involved.

I understand that I will have periodic blood tests to monitor my blood levels of testosterone, and I consent to such testing. I understand that the treatment provided by Matrix Hormones does NOT replace a full physical exam by my personal physician, and I agree to have my personal physician perform an annual checkup to monitor basic health factors.

I understand that each patient is different and there are no guarantees as to the results obtainable from TRT treatment. TRT is not a cure, and if I stop treatment, symptoms may return or worsen.

I am not currently attempting to father children. If this changes, I will advise my provider at Matrix Hormones immediately.

I do not have and have not been diagnosed with cancer.

Patient Statement of Understanding:
I have read and fully understand the above information related to participation in Matrix Hormones treatment program(s). I have also had the opportunity to ask questions regarding these issues. I accept these specific policy rules.

This document is intended to provide information about Testosterone Replacement Therapy and its potential risks and benefits. It should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

Informed Consent for HCG Use with Testosterone Replacement Therapy

I understand that HCG should be part of every good Testosterone Replacement Therapy (TRT) protocol if the aim is to mimic the natural physiological processes that occur within the body.

I also understand that testosterone monotherapy is a short-sighted approach to treating Testosterone Deficiency when we know other hormones are suppressed through treatment. Therefore, HCG is recommended to all new patients on testosterone therapy, irrespective of the need to retain fertility, as it is often the difference between feeling good and feeling great.

Potential Consequences of Testosterone Use without HCG:
- When using Testosterone, my natural production of testosterone and my testicles may shut down. HCG will typically slow this process down and prevent the testicles from going into complete atrophy.
- Around 60-70% of males on testosterone replacement need to be on HCG permanently or they need to cycle HCG once or twice a year to prevent/stop testicular shrinkage and pain, low libido, erectile dysfunction, delayed orgasm, penile sensitivity, decreased ejaculation, and possibly issues with energy, cognition, and mood.
- When first starting testosterone treatment, I may experience shrinkage and pain because testosterone levels rise quickly while slamming down on the testicle's natural production. HCG should be used alongside testosterone during each cycle, but at a minimum, it should be added to my first cycle as my body eases into therapy.
- If I opt-out of HCG, there is a risk that my testicles will go into complete atrophy. If I ever decide to come off testosterone treatment, keeping the testicles from going into complete atrophy makes it easier to attempt to restart my own natural production.
- If I experience shrinkage and pain down the road and wish to add on HCG at that time, there is no guarantee that HCG can fully recover some or any of the size lost.

Fertility Considerations:
- HCG is required if I am concerned about fertility or remaining fertile, and I will not be treated with Testosterone if I opt-out of HCG.
- HCG is required for each cycle of testosterone if I am under 30 years old, and I will not be treated with Testosterone if I opt-out of HCG.
- If I am not concerned with fertility and am over 30 years of age and opt-out of HCG, I understand the potential risks.

Alternatives to HCG:
I understand that a small percentage of men do not tolerate HCG well, and if I am one of them, options to replace it include enclomiphene, HCG cycling, gonadorelin, or clomiphene.

Patient Acknowledgment:
I have been informed of the benefits of using HCG alongside Testosterone Replacement and the risks of opting-out. I have had the opportunity to ask questions and have received satisfactory answers to any questions I have raised.

By agreeing below, I acknowledge that I have read, understood, and agree to the terms outlined in this informed consent document.

This document is intended to provide information about the use of HCG with Testosterone Replacement Therapy and its potential risks and benefits. It should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

Informed Consent for Telemedicine Services

Telemedicine (eVisit) involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up, and/or education, and may include any of the following:

- Patient medical records
- Medical images
- Live two-way audio and video
- Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
- Improved access to medical care by enabling a patient to initiate a visit and consult a healthcare practitioner at a distant/other sites
- More efficient medical evaluation and management
- Obtaining expertise of a distant specialist

Possible Risks:
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s)
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment
- In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
- In rare cases, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors

By agreeing to this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
8. I understand that I am not allowed to record any or all parts of the e-visit encounter with the healthcare provider.
9. I understand that some medical conditions may require a physical exam; therefore, not every medical condition can be fully addressed by an electronic visit.
10. I understand that e-visits are cash pay visits. My credit card will be charged based on the time spent in the visit (nonrefundable).
11. I understand that it is my responsibility to ensure a secure and private environment during the telemedicine visit to protect my own confidentiality.

Patient Consent To The Use of Telehealth:
I have read this form or had it read and explained to me in full. I fully understand its contents, including the risks, benefits, and alternatives.

I have been given the opportunity to ask questions, and any questions have been answered to my satisfaction.

I hereby give my informed consent to the use of telehealth in the course of my diagnosis and treatment.

This document is intended to provide information about telemedicine services and its potential risks. It should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

Our Uses and Disclosures
We typically use or share your health information in the following ways:
- Treat you
- Run our organization
- Bill for your services
We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Electronic Access
We provide electronic access to your health information via the MD HQ Patient Portal.

Additional Information
- We may contact you for appointment reminders, treatment alternatives, or other health-related benefits and services that may be of interest to you.
- We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information.
- We may disclose your protected health information to a public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability.
- If you are a member of the armed forces, we may release your protected health information as required by military command authorities.
- We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

By agreeing below, you acknowledge receipt of this notice.

Consent for Marketing Communications

The law requires that we obtain your consent to contact you for marketing purposes, which may include, but are not limited to, the following:

Promotions
Specials
Offers
New services
Discounts

The contact information you provided on your intake paperwork, including your mail, email, telephone, cellphone, and/or text message details, will be used for solicitation purposes. Communications may include the use of pre-recorded voice messages, email, SMS, direct dial calls, and autodial systems.

By checking this box, you certify that:

You have read and agree to the above solicitation method(s).
You were not previously solicited by any of the above means prior to the date indicated below.
At any time, if you choose to opt-out, you will notify Matrix Hormones in writing or by the opt-out method(s) provided in the communication you receive.

Please note:

Your consent to receive marketing communications is not a condition of purchasing any goods or services from Matrix Hormones.

You may revoke your consent at any time by following the opt-out instructions provided in the marketing communications or by contacting Matrix Hormones directly.

Matrix Hormones will not share or sell your personal information to third parties for their marketing purposes without your explicit consent.

You have the right to request a copy of this consent form for your records.

By agreeing below, you acknowledge that you have read, understood, and agree to the terms of this consent for marketing communications.

Consent for SMS Communications

Matrix Hormones respects your privacy and autonomy in choosing how we communicate with you. To comply with legal requirements and ensure we engage with you via your preferred methods, we seek your explicit consent for communications through SMS, which may include:

Exclusive promotions and specials
Tailored offers
Updates on new services
Personalized discounts
Member-only deals

SMS Communications Consent: When you provide your mobile number and check the box below, you expressly consent to receive SMS messages from Matrix Hormones.

This may involve messages delivered via an automated system, and standard message and data rates may apply.

Please acknowledge your consent for SMS: I have read and explicitly consent to receive SMS messages from Matrix Hormones about promotions, specials, offers, new services, and discounts.

I confirm that I am providing this consent freely and have not been previously solicited by SMS prior to providing my mobile number.

I understand that I can opt out of SMS communications at any time by replying "STOP" to any message I receive, or by other means provided in the SMS communication, and that my opt-out will be effective upon Matrix Hormones' receipt and processing of my request.

I am aware that my consent to receive SMS messages is not required to purchase any goods or services from Matrix Hormones, and I can choose other forms of communication messages.

I understand that I may revoke my consent at any time and request a copy of this consent form by contacting Matrix Hormones directly. Matrix Hormones commits to maintaining the confidentiality of your personal information and will not share or sell your details to third parties.

Affirmation of Consent: By Agreeing below, I confirm that I have thoroughly read, fully understood, and agree to the terms of this SMS communications consent form.

If you have questions or need further clarification about this consent form or our SMS practices, please contact our SMS Manager at [email protected].

It is important that you understand the risks and benefits associated with Testosterone Replacement Therapy (TRT) before beginning or continuing treatment. TRT is not a new area of medicine and is used for the treatment of a medical condition known as hypogonadism in males. It is important that you consider the information provided and discuss it carefully with your provider. Be sure that you are doing what is right for you. If you are unsure, then you should refuse and/or discontinue treatment.

The medications that may be prescribed as part of your treatment may include Testosterone, HCG, Anastrozole, Clomiphene, as well as Vitamin D, B12, and other dietary supplements, where indicated. Recommended treatment in some instances may include “off-label” drug use of an FDA-approved medication. Testosterone is FDA-approved only for use in men who lack or have low testosterone levels in conjunction with associated symptoms. These symptoms are often related to male andropause or aging and may include decreases in energy and motivation, poor concentration or memory, feelings of depression or irritability, sleep disturbances, reduced muscle mass, increased body fat, and reduced sexual desire or libido.

These symptoms may be treatable in hypogonadal males utilizing testosterone. The therapeutic objective of TRT is to restore normal testosterone levels, helping to reduce these symptoms. There are a number of potential side effects related to TRT. You should discuss each of these with your medical provider. Side effects may include:
– Increased red blood cells
– Acne
– Sleep apnea
– Breast enlargement
– Testicular atrophy
– Lowered sperm count
– Mood swings
– Injection site reactions such as bleeding, pain, swelling, redness, or infection
– Increased estrogen production
– Fluid retention

TRT is not recommended for patients who have breast or prostate cancer. You should also be aware that some recent studies have associated TRT with increased risk for adverse cardiovascular events, such as blood clots, heart attacks, or strokes, in certain types of patients. If you have a history of cardiac or urologic problems, your provider may require clearance from your cardiologist or urologist prior to initiating treatment. Each patient’s own risks can vary depending upon health history and lifestyle. It is important that you provide an accurate and complete medical history to your provider.

Patient Consent:
I have read and understand that there may be complications arising from or related to treatment as described above and explained by my treating medical provider. I have had an opportunity to discuss my complete past medical and health history, including any serious problems and/or injuries, as well as my family history of diseases and conditions, with my provider. All of my questions concerning the risks, benefits, and alternatives to treatment have been answered. I am satisfied with the answers and desire to commence treatment, knowing the risks and potential side effects involved.

I understand that I will have periodic blood tests to monitor my blood levels of testosterone, and I consent to such testing. I understand that the treatment provided by Matrix Hormones does NOT replace a full physical exam by my personal physician, and I agree to have my personal physician perform an annual checkup to monitor basic health factors.

I understand that each patient is different and there are no guarantees as to the results obtainable from TRT treatment. TRT is not a cure, and if I stop treatment, symptoms may return or worsen.

I am not currently attempting to father children. If this changes, I will advise my provider at Matrix Hormones immediately.

I do not have and have not been diagnosed with cancer.

Patient Statement of Understanding:
I have read and fully understand the above information related to participation in Matrix Hormones treatment program(s). I have also had the opportunity to ask questions regarding these issues. I accept these specific policy rules.

This document is intended to provide information about Testosterone Replacement Therapy and its potential risks and benefits. It should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

Informed Consent for HCG Use with Testosterone Replacement Therapy

I understand that HCG should be part of every good Testosterone Replacement Therapy (TRT) protocol if the aim is to mimic the natural physiological processes that occur within the body.

I also understand that testosterone monotherapy is a short-sighted approach to treating Testosterone Deficiency when we know other hormones are suppressed through treatment. Therefore, HCG is recommended to all new patients on testosterone therapy, irrespective of the need to retain fertility, as it is often the difference between feeling good and feeling great.

Potential Consequences of Testosterone Use without HCG:
– When using Testosterone, my natural production of testosterone and my testicles may shut down. HCG will typically slow this process down and prevent the testicles from going into complete atrophy.
– Around 60-70% of males on testosterone replacement need to be on HCG permanently or they need to cycle HCG once or twice a year to prevent/stop testicular shrinkage and pain, low libido, erectile dysfunction, delayed orgasm, penile sensitivity, decreased ejaculation, and possibly issues with energy, cognition, and mood.
– When first starting testosterone treatment, I may experience shrinkage and pain because testosterone levels rise quickly while slamming down on the testicle’s natural production. HCG should be used alongside testosterone during each cycle, but at a minimum, it should be added to my first cycle as my body eases into therapy.
– If I opt-out of HCG, there is a risk that my testicles will go into complete atrophy. If I ever decide to come off testosterone treatment, keeping the testicles from going into complete atrophy makes it easier to attempt to restart my own natural production.
– If I experience shrinkage and pain down the road and wish to add on HCG at that time, there is no guarantee that HCG can fully recover some or any of the size lost.

Fertility Considerations:
– HCG is required if I am concerned about fertility or remaining fertile, and I will not be treated with Testosterone if I opt-out of HCG.
– HCG is required for each cycle of testosterone if I am under 30 years old, and I will not be treated with Testosterone if I opt-out of HCG.
– If I am not concerned with fertility and am over 30 years of age and opt-out of HCG, I understand the potential risks.

Alternatives to HCG:
I understand that a small percentage of men do not tolerate HCG well, and if I am one of them, options to replace it include enclomiphene, HCG cycling, gonadorelin, or clomiphene.

Patient Acknowledgment:
I have been informed of the benefits of using HCG alongside Testosterone Replacement and the risks of opting-out. I have had the opportunity to ask questions and have received satisfactory answers to any questions I have raised.

By agreeing below, I acknowledge that I have read, understood, and agree to the terms outlined in this informed consent document.

This document is intended to provide information about the use of HCG with Testosterone Replacement Therapy and its potential risks and benefits. It should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

Informed Consent for Telemedicine Services

Telemedicine (eVisit) involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up, and/or education, and may include any of the following:

– Patient medical records
– Medical images
– Live two-way audio and video
– Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
– Improved access to medical care by enabling a patient to initiate a visit and consult a healthcare practitioner at a distant/other sites
– More efficient medical evaluation and management
– Obtaining expertise of a distant specialist

Possible Risks:
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
– In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s)
– Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment
– In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
– In rare cases, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors

By agreeing to this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
8. I understand that I am not allowed to record any or all parts of the e-visit encounter with the healthcare provider.
9. I understand that some medical conditions may require a physical exam; therefore, not every medical condition can be fully addressed by an electronic visit.
10. I understand that e-visits are cash pay visits. My credit card will be charged based on the time spent in the visit (nonrefundable).
11. I understand that it is my responsibility to ensure a secure and private environment during the telemedicine visit to protect my own confidentiality.

Patient Consent To The Use of Telehealth:
I have read this form or had it read and explained to me in full. I fully understand its contents, including the risks, benefits, and alternatives.

I have been given the opportunity to ask questions, and any questions have been answered to my satisfaction.

I hereby give my informed consent to the use of telehealth in the course of my diagnosis and treatment.

This document is intended to provide information about telemedicine services and its potential risks. It should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
– Get a copy of your paper or electronic medical record
– Correct your paper or electronic medical record
– Request confidential communication
– Ask us to limit the information we share
– Get a list of those with whom we’ve shared your information
– Get a copy of this privacy notice
– Choose someone to act for you
– File a complaint if you believe your privacy rights have been violated

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

Our Uses and Disclosures
We typically use or share your health information in the following ways:
– Treat you
– Run our organization
– Bill for your services
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Our Responsibilities
– We are required by law to maintain the privacy and security of your protected health information.
– We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
– We must follow the duties and privacy practices described in this notice and give you a copy of it.
– We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Electronic Access
We provide electronic access to your health information via the MD HQ Patient Portal.

Additional Information
– We may contact you for appointment reminders, treatment alternatives, or other health-related benefits and services that may be of interest to you.
– We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information.
– We may disclose your protected health information to a public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability.
– If you are a member of the armed forces, we may release your protected health information as required by military command authorities.
– We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

By agreeing below, you acknowledge receipt of this notice.

Consent for Marketing Communications

The law requires that we obtain your consent to contact you for marketing purposes, which may include, but are not limited to, the following:

Promotions
Specials
Offers
New services
Discounts

The contact information you provided on your intake paperwork, including your mail, email, telephone, cellphone, and/or text message details, will be used for solicitation purposes. Communications may include the use of pre-recorded voice messages, email, SMS, direct dial calls, and autodial systems.

By checking this box, you certify that:

You have read and agree to the above solicitation method(s).
You were not previously solicited by any of the above means prior to the date indicated below.
At any time, if you choose to opt-out, you will notify Matrix Hormones in writing or by the opt-out method(s) provided in the communication you receive.

Please note:

Your consent to receive marketing communications is not a condition of purchasing any goods or services from Matrix Hormones.

You may revoke your consent at any time by following the opt-out instructions provided in the marketing communications or by contacting Matrix Hormones directly.

Matrix Hormones will not share or sell your personal information to third parties for their marketing purposes without your explicit consent.

You have the right to request a copy of this consent form for your records.

By agreeing below, you acknowledge that you have read, understood, and agree to the terms of this consent for marketing communications.

Consent for SMS Communications

Matrix Hormones respects your privacy and autonomy in choosing how we communicate with you. To comply with legal requirements and ensure we engage with you via your preferred methods, we seek your explicit consent for communications through SMS, which may include:

Exclusive promotions and specials
Tailored offers
Updates on new services
Personalized discounts
Member-only deals

SMS Communications Consent: When you provide your mobile number and check the box below, you expressly consent to receive SMS messages from Matrix Hormones.

This may involve messages delivered via an automated system, and standard message and data rates may apply.

Please acknowledge your consent for SMS: I have read and explicitly consent to receive SMS messages from Matrix Hormones about promotions, specials, offers, new services, and discounts.

I confirm that I am providing this consent freely and have not been previously solicited by SMS prior to providing my mobile number.

I understand that I can opt out of SMS communications at any time by replying “STOP” to any message I receive, or by other means provided in the SMS communication, and that my opt-out will be effective upon Matrix Hormones’ receipt and processing of my request.

I am aware that my consent to receive SMS messages is not required to purchase any goods or services from Matrix Hormones, and I can choose other forms of communication messages.

I understand that I may revoke my consent at any time and request a copy of this consent form by contacting Matrix Hormones directly. Matrix Hormones commits to maintaining the confidentiality of your personal information and will not share or sell your details to third parties.

Affirmation of Consent: By Agreeing below, I confirm that I have thoroughly read, fully understood, and agree to the terms of this SMS communications consent form.

If you have questions or need further clarification about this consent form or our SMS practices, please contact our SMS Manager at [email protected].