I voluntarily request the use of Testosterone from Dr. Malhotra’s and his team, along with strict lifestyle restrictions, like limiting alcohol intake, smoking or taking extra supplements. I understand that initial blood tests are necessary to rule out any conditions that would disqualify me from the program. I understand there is no guarantee for the effectiveness of Testosterone. I agree that I am and will be under the care of another medical provider for all other conditions. Dr. Malhotra can work in conjunction with, but cannot replace, my regular primary care physicians, such as general practitioners or other specialists in family medicine or internal medicine.
Prior to my treatment, I have fully disclosed any medical conditions or diseases such as history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorder (anemia, thalessemia, hemophilia, etc.) emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. Further contraindications are outlined below. If I fail to disclose any medical condition that I have, I release the doctor and facility from any liability associated with the use of Testosterone.
Testosterone therapy can have both desired effects and potential side effects. The side effects of testosterone therapy can vary from person to person and may depend on factors such as dosage, duration of therapy, individual response, and underlying health conditions. It's important to discuss these potential side effects with a healthcare professional before starting testosterone therapy. Here are some commonly reported side effects:
1.Acne: Testosterone therapy can increase oil production in the skin, leading to acne breakouts.
2.Fluid Retention: Some individuals may experience fluid retention, leading to swelling in the ankles and feet.
3.Breast enlargement: Testosterone can convert to estrogen in the body, leading to breast tissue development or enlargement (gynecomastia). This side effect is more common in higher dosages.
4.Prostate issues: Testosterone therapy may cause an enlargement of the prostate gland or worsening of existing prostate conditions, such as benign prostatic hyperplasia (BPH). It is important to monitor prostate health through regular check-ups.
5.Sleep apnea: Testosterone therapy may worsen sleep apnea or increase the risk of developing it.
6.Changes in cholesterol levels: Testosterone therapy can affect lipid profiles, potentially leading to increases in cholesterol levels.
7.Mood changes: Some individuals may experience mood swings, irritability, or increased aggression.
8.Skin reactions: Testosterone therapy can cause skin reactions at the injection site, such as redness, itching, or irritation.
9.Hair loss: Testosterone therapy can accelerate male pattern baldness in individuals who are genetically predisposed to it.
10.Suppression of natural testosterone production: Long-term testosterone therapy can suppress the body's natural testosterone production. When discontinuing therapy, it may take time for the body to resume normal testosterone production.
I agree to immediately report any problems that might occur to my medical provider during the treatment program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase risks and alter my results from the program. If I do not follow these recommendations and restrictions, I agree to release the doctor and facility from any liability arising as a result of this.
I understand that I may quit the program at any time. While adverse side effects or complications are not expected, in the event that an illness does occur, I understand that I need to contact Dr. Malhotra (email at info@myzoomclinic.com and Cell 713-367-1059). If I experience an emergency situation, I understand that I need to go to an emergency facility.
I understand that if there are any changes in my medical history or there are any changes in my medications or any other changes relevant to this procedure, I will advise Dr. Malhotra at that time.
I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release the doctor and the facility from any liability associated with this procedure. In the event a dispute arises over the outcome of the procedure, I consent solely to arbitration as a legal means of settlement.

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Patient’s Name Signed:

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Provider’s Name Printed: Dr. Advitya Malhotra and his team associates