The Menopause Clinic Patient Registration Form

Payment Terms & Conditions

Payments will be made at the time of the appointment. All other appointment payments are due at the time of your consultation. No payment will be taken without you being notified beforehand. Failure to make payment may result in the matter being referred to our Debt Collection Agents whose charges may be added to the invoice amount and treatment being cancelled.

Declaration

The Menopause Clinic is the trading name of VIP Medical Clinic Ltd., a company wholly owned by Deborah & Christopher Vines, a company in which some of the practising Healthcare Professionals have a financial interest. This interest will not influence clinical decisions affecting your care.

In the interests of training and development there may be other healthcare professionals in attendance at your consultation. These individuals will be introduced to you at the time of your appointment. Please inform your Healthcare Professional if you do not wish anyone to be present for your consultation.

Only formal requests by email would be accepted for retrieval of this data to external sources. The Menopause Clinic takes responsibility for the safety of your personal identifiable data extremely seriously. Photography and Imaging may be used as part of your diagnosis and/or treatment. A copy of this patient information record and patient consent form is retained on your patient file, which is kept electronically within The Menopause Clinic.

Please be aware that we share personal information with external companies, with your written consent. This can include providers such as: TDL, Nationwide Pathology, Genova Diagnostics, Specialist Pharmacy, and your next of kin.

Patient Data Consent

I have or will be receiving a full explanation of the nature of the treatment(s) to be provided to me by The Menopause Clinic. I confirm that I understand and accept these treatments.

I understand that my Healthcare Professional is bound by and will adhere to the NMC (Nursing & Midwifery Council) Code of Conduct at all times.

Under the provisions of the Data Protection Act 1998 and GDPR, I understand that my Healthcare Professional needs my consent to keep information about me and my health on the practice computer system.

I understand that the information that my Healthcare Professional may hold can include my personal identification data (name, address, telephone numbers, credit card etc.), details of my medical condition(s) and any medication prescribed to me, that is necessary to provide a treatment to me.

I agree that The Menopause Clinic may hold, update and use my information for the purposes of monitoring and improving that service. It may also anonymise this information and use it for research purposes.

I understand that my personal information will not be provided to other health professionals or organisations without my permission. I also understand that in some circumstances other Healthcare Professionals at The Menopause Clinic or admin staff may need to access my file.

I understand I have the right to gain access to and to correct this information. I understand that I am entitled to change my consent at any time, and I will request a new consent form from The Menopause Clinic, if I wish to alter my consent.

Informed Consent for Bio-Identical and Body Identical Hormone Therapy (BHRT)

Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy we feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed.

Bio-Identical and Body Identical hormones have the exact same chemical structure with your own hormones. Your Bio-Identical Hormone prescription is made in a compounding pharmacy, and the dose is adjusted to your needs. As it is not a fixed dose combination, this medication is unlicensed. BHRT is often prescribed to women during perimenopause (the time from first symptoms to up to several years beyond the last period) and menopause (starting one year after the last period) for symptoms of hot flushes, vaginal dryness, loss of libido, depression, irritability or PMS like symptoms, bone loss and osteoporosis or its prevention, and cardiovascular disease. Sometimes, hormone therapy may be recommended for PMS, polycystic ovarian syndrome (PCOS), endometriosis or hormonal acne. This may be recommended in addition to nutritional advice or psychological support.

Hormone Replacement Therapy (HRT) is approved by the FDA only for hot flushes and osteoporosis. Using it for other symptoms or problems is considered “off label” use, and the burden is on the physician to be sure that there is adequate science to support the use in each situation.

Your Body Identical Hormone prescription is off the shelf licensed medication and is available is specific doses, the is not classed as bespoke medication.

Potential Benefits

When hormone levels are brought back to “normal” for your age, there is much evidence that your overall health benefits. The risk of osteoporosis and fractures may decrease. Oestrogen therapy is the most effective treatment for hot flushes. There may be other long term beneficial effects of treatment, such as improved sleep, mood and memory.

Bioidentical hormone therapy may contain one or any combination of the following hormones: oestrogens (oestradiol and estriol), progesterone, testosterone and dehydroepiandrosterone (DHEA). Thyroid hormones (thyroxine and triiodothyronine) may also be prescribed depending on your needs.

Licensed Body Identical hormones contain oestrogens and progesterone’s.

Risks

Studies showed that using oestrogen alone had decreased risk of breast cancer but an increased risk of endometrial cancer. Subsequent studies added synthetic progesterone to HRT, which protected the lining of the womb against endometrial proliferation. It is now thought that the combination of oestrogen and progestins (synthetic progesterone) increases the risk of breast cancer over oestrogen alone. The risk of breast cancer depends on a few other lifestyle and genetic factors, such as obesity, alcohol and smoking; please discuss this further with your doctor.

There is no sufficient data to fully quantify the risks associated with bioidentical progesterone, rather than synthetic progestins, although preliminary data from cohort studies so far may suggest less risk.

The Menopause clinic protocols recommend routine pelvic ultrasound as well as a mammogram/ breast ultrasound and how often these tests are recommended depends on your risk factors and your doctor will advise you accordingly.

Please read the following and sign

I understand that there are benefits of this treatment if successful, and I also understand that the Healthcare Professional cannot be sure that the treatment will fully help me.

I have discussed the reasons for taking hormones with the Healthcare Professional and understand why she is prescribing them, and the risks associated with taking hormones, including but not limited to the possibility of increased risk of breast and/or endometrial cancer, blood clotting stroke or heart attack.

The risks and potential side effects associated with Bio-Identical and Body Identical Hormone Replacement Therapy (BHRT) have been explained to me, and I have had the opportunity to ask any questions concerning this treatment.

I confirm I have read, understood and accepted the terms, information, risks and potential benefits listed above (or alternatively had these explained to me). I understand that I am ultimately responsible for the payment of my accounts should any insurer or third-party sponsor not pay in full. For circumstances not involving payment, I agree that the above information is up to date and correct at the time of signing.