To the Patient: Background: You have been diagnosed with or have an increased risk of having suboptimal thyroid hormone function. So, you may benefit from thyroid hormone supplementation. Your doctor has recommended treatment with oral thyroid hormone replacement therapy(ies). Thyroid pharmaceuticals (i.e. Synthroid and Cytomel) are FDA approved for use in humans. Bio-Identical compounded thyroid preparations that may be prescribed for you are regulated by pharmacy compounding law. The use of these therapies as it relates to your diagnosis is considered an integrative treatment, and treatment is also considered controversial unless your thyroid tests were overtly abnormal. You have the right, as a patient, to be informed about your condition and the recommended conventional, integrative, complementary, alternative, non-conventional or non-standard procedures to be used so that you make an informed decision whether or not to undergo the procedures after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is simply to make you better informed so you may give or withhold your consent to the procedure or treatment. NOTICE: Refusal to consent to the innovative, integrative, complementary or nonstandard procedure shall not affect your right to future care or treatment.
Therapeutic Basis: There is concern that thyroid deficiency is often missed by standard blood testing, and may contribute to fatigue, high cholesterol, and inability to lose weight. It has been estimated that many if not most patients with underactive thyroids will test normal by traditional standards. Thyroid hormone replacement therapy can be used to augment thyroid hormone levels in a number of conditions beyond overt thyroid failure, and your practitioner will decide if a clinical trial is warranted based on lab and clinical findings, and may recommend thyroid supplementation when most non holistic physicians would not. Therefore this treatment, while common in alternative and weight loss practices, is debated in the traditional medical community. Your physician may recommend any of a number of forms of thyroid hormone. If taking T3 or cytomel at doses over 35 mcg, these are considered very high doses, often given for suspected thyroid receptor resistance. This is associated with a greater risk of heart attack or abnormal heart rhythms, osteoporosis, anxiety or symptoms of hyperthyroidism, or other toxicities. I will notify my physician immediately if side effects occur on the thyroid. I recognize that blood testing is not likely to be reliable on high dose T3 and that dosing is adjusted based on clinical signs and symptoms. Objectives: Thyroid hormone replacement therapy is implemented to optimize hormone levels in the blood and thyroid function, helping to reduce symptoms associated with low levels of these hormones. Potential Risks: Safety of any of these hormones during pregnancy cannot be guaranteed. Notify your physician or if you are pregnant, suspect that you have become pregnant, or if you are planning to become pregnant during this therapy. None the less, optimal thyroid dosing during pregnancy is critical to both the mother and baby being healthy with inadequate thyroid hormone replacement possibly contributing to a marked increase in fetal deaths/miscarriages. Adverse side effects of any thyroid hormone replacement can include rapid heartbeat, irregular heartbeat, chest pain or tightness or heart attack, heart failure, shortness of breath, anxiety, nervousness, irritability, sleeplessness, tremors, excessive sweating, heat intolerance, weight loss, or changes in menstrual periods, or death. If you have a history of heart palpitations or have ever been diagnosed with a heart/cardiac condition, notify your
primary care physician before beginning any thyroid replacement therapy.
Statement of patient:
I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include
laboratory evaluation of T3, T4, TSH, Reverse T3, and thyroid antibody levels. I agree to see my primary care
physician or other practitioner should side effects result from this therapy that warrant further medical evaluation.
I agree to immediately report to my physician any adverse reaction or problem that might be related to my therapy. Because thyroid hormone preparations vary significantly, I agree to discuss any change in my therapy with
I agree to immediately report to my physician any adverse reaction or problem that might be related to my
therapy. I understand that along with the benefits of any medical treatment or therapies, there are both risks and
potential complications to treatment, as well as to not being treated. Those risks and potential complications have
been explained to me and I agree that I have received sufficient information regarding those risks, potential
complications and benefits and have had all my questions sufficiently answered. Furthermore, I have not been promised or guaranteed any specific benefit from the administration of thyroid hormone replacement therapy. I
I certify this form has been fully explained to me, that I have read it or have had it read to me and that I
Signature of Patient ____________________________________
Name (PRINT) ____________________________________________________________________________
If patient is a minor Parent/Legal Guardian Signature ________________________ Date ________________
Name (PRINT) ____________________________________________________
Statement of clinical educator:
I have explained the therapy, its intended benefits and risks, and possible reactions to the patient. I have confirmed that the patient has no further questions and wishes to initiate thyroid hormone replacement therapy.
Name of Physician Explaining Procedures: ________________________________________
I have explained the risks and benefits of the therapy as detailed above. The patient has verbalized to me his/her
understanding of those risks and benefits giving verbal consent to initiate this therapy.
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1. Your patient’s MAR has the following order: Motrin Elixer 6.2 ml PO every 6 hours PRN for pain. On hand is Motrin 100 mg / ½ tsp. How many mgs of Motrin will your patient receive with each dose of 6.2 ml? Your patient weighs 27 kg and the maximum recommended safe dosage is 10 mg/kg/dose. Is the ordered dose safe to give? Order: 6.2 ml x 100 mg x 1 tsp = 248 mg Max. RSD : 27 kg x 10 mg
CONSENT FOR THYROID HORMONE REPLACEMENT THERAPY