Mammogram Waiver for Testosterone and/or Estradiol Pellet Therapy
I, _____________________________________, voluntarily choose to undergo implantation of subcutaneous
bio-identical testosterone and/or estradiol pel et therapy, even though I am not current on my yearly
mammogram. I understand that such therapy is controversial and that many doctors believe that estradiol
replacement in my case is contraindicated. My Treating Provider has informed me it is possible that taking
estradiol could possibly cause cancer, or stimulate existing breast cancer (including one that has not yet been
detected). Accordingly, I am aware that breast cancer or other cancer could develop while on pel et therapy.
For today’s appointment I DO NOT have a mammogram for the fol owing reason: ( ) My decision not to have one. ( ) Unable to provide the report at this time. ( ) My doctor’s decision not to have one. Please provide a note from your treating physician with their
rationale as to why they don’t want you to have a mammogram.
I am aware that a current report must be sent by mail or faxed to our office prior to my next HRT
appointment. The Treating Provider has discussed the importance and necessity of a mammogram since I
receive testosterone and/or estradiol. __________ (initials of patient)
I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the
risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was
I understand that mammograms are the best single method for detection of early breast cancer. I understand
that my refusal to submit to a mammogram test may result in cancer remaining undetected within my body. I
acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including
death and/or breast, uterine or cancer issues) that may be sustained by me in connection with my decision to
not have a mammogram and undergo testosterone and/or estradiol pel et therapy including, without
limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current
cancer or a new cancer. I hereby release and agree to hold harmless Dr. Donovitz, Treating Provider, BioTE
Medical®, LLC., and any of their BioTE Medical® physicians, nurses, officers, directors, employees and agents
from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness,
injury or accident that may be sustained by me as a result of testosterone and/or estradiol pellet therapy. I
acknowledge and agree that I have been given adequate opportunity to review this document and to ask
questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns
___________________________________________ _____________________________________________________ ______________________
Patient Print Name Signature Today’s Date
___________________________________________ _____________________________________________________ ______________________
Provider Print Name Signature Today’s Date
5 Edible Teacher’s notes Ask the students to think about their favourite Number 1. A little chocolate each day is good for dish and explain what the ingredients are and, if your health. Chocolate contains antioxidants which possible, how to make it to the class. Extend the help to protect the body against cancer. It also discussion to typical dishes from their country or c