1. Circle Care Center
618 West Ave
Norwalk, CT 06850
www.circlecarecenter.org
PH: (203) 852-9525
FAX: (203) 854-0371
Client Information for Informed Consent
TESTOSTERONE FOR TRANSGENDER CLIENTS/Minors and Parents/Guardians
What is testosterone?
It isthe sex hormone thatmakescertainfeaturesappeartypicallymale.Itbuildsmuscle andcausesthe developmentof
facial hairand a deepervoice.
How is testosterone taken?
It isusuallyinjectedeveryone tofourweeks.Itisnotusedas a pill because the bodymaynotabsorb itproperly.Andit
may cause liverproblems.Somepeople use skincreamsandpatches,buttheytendtobe more expensive.
The dosesusedforinjectiondifferfromproducttoproduct andfrom patienttopatient.Theymayrange from100 to
400mg. The injectionsare made ina large muscle toslow the release of the hormone.Butthere maybe unwanted
swingsinhormone levels.Youmaycontrol the swingsbychanginghow oftenthe dose isgiven,how muchof a dose is
given,orby switchingtoa creamor a patch.
Before usingmedications to transition and feminize, you and your parents or guardians need to know the possible
advantages,disadvantagesandrisksof these medications.We have listed them here for you. It's important that you
understand all of this information before you begin taking these medications.
Please read the following with your parent or guardian. Once your questions or concerns are addressed, and you
have decided to proceed with the medication(s), both you and your parent or guardian will need to sign this
information and consent form.
We are happy to answer any questions you have.
Warning– Whoshould not take testosterone
It shouldnotbe usedby anyone whoispregnantor hasuncontrolledcoronaryarterydisease
It shouldbe usedwithcautionandonlyaftera full discussionof risksbyanyone whohas:
• acne
• a familyhistoryof heartdiseaseorbreastcancer
• has a bloodclot
• highlevelsof cholesterol
• liverdisease
• obese
• smokescigarettes
Periodicbloodteststocheckonthe effectsof the
hormone will be needed.Routine breastexams
and pelvicexamswithPaptestsshouldbe
continued,whenapplicable.

2. 2
Please initial and date each statementon this form to show that youunderstandthe benefits,risks,andchangesthat
may occur fromtakingtestosterone.
Masculinizing
I knowthat testosterone maybe prescribedtomake me appearless like awomanandmore like aman.
I knowit can take several monthsorlongerforthe effectstobecome noticeable.Iknow thatnoone can predict
howfast — or howmuch — change will happen.Iknow thatthe changesmay not be complete fortwoto five
yearsafterI start.
I knowthat the followingchangesare likelyandpermanentevenif Istoptakingtestosterone:
• biggerclitoris — typicallyabouthalf aninchtoa little more thananinch
• deepervoice
• gradual growthof moustache andbeard
• hairlossat the templesandcrownof the head — possibilityof beingcompletelybald
• more,thicker,andcoarserhairson abdomen,arms,back,chest,and legs
I knowthat the followingchangesare usuallynotpermanent — theyare likelytogoaway if I stoptaking
testosterone:
• acne (manypermanentlyscar)
• menstrual periodstypicallystopone tosix monthsafterstarting
• more abdominal fat– redistributedtoamale shape:decreasedonbuttocks,hips,andthighs;increasedin
abdomen – changingfrom―pearshape‖to ―apple shape
• more muscle massandstrength
• more sex drive
• vaginal dryness
BENEFITS
• appearingmore like aman
› biggerclitoris*
› coarser skin
› lowervoice *
› more body hair*
› more facial hair*
› more muscle mass
› more strength
› no more menstrual periods
• more physical energy
• more sex drive
• protectionagainstbone thinning
(osteoporosis)
*These are permanentchanges.
RISKS
• acne (maypermanently scar)
• bloodclots(thrombophlebitis)
• emotional changes — forexample,more aggression
• headache
• highbloodpressure (hypertension)
• increasedred-blood-cellcount
• infertility
• inflamedliver
• interactionwithdrugsfordiabetesandbloodthinning
— forexample CoumadinandWarfarin
• male patternbaldness
• more abdominal fat — redistributedtoamale shape*
• more riskof heartdisease
• swellingof hands,feet,andlegs
• weightgain

3. 3
I knowthat the effectsof testosterone onfertilityare unknown.Ihave beentoldthatImay or may not be able
to getpregnantevenif I stoptakingtestosterone.Iknow thatI mightstill getpregnantevenaftertestosterone
stopsmy menstrual periods.Iknowaboutmy birthcontrol options(if applicable).AndIknow thatI can’t take
testosterone if Iampregnant.
I knowthat some aspectsof my bodywill notbe changed:
• Losingsome fatmay make my breastsappearslightlysmaller,buttheywill notshrinkverymuch.
• Althoughmyvoice will deepen,otheraspectsof the wayI speakmaynot soundmanlier.
I knowthat there are othertreatmentsthatmay be helpful tomake mybreastssmallerormy speechmanlier.If
I have concerns,I knowyoucan give me referralstohelpme explore treatmentoptions.
Risks ofTestosterone
I knowthe medical effectsandthe safetyof testosterone are notcompletelyknown.There maybe long-term
risksthat are notyetknown.
I knownot to take more testosterone thanprescribed.I know itincreaseshealthrisks.Iknow thattakingmore
than I am prescribedwon’tmake changeshappenmore quicklyormore significantly.Iknow mybodycan
convertextratestosterone intoestrogen,andthatcan slow downor stop myappearingmanlier.
I knowthat testosterone cancause changesthatincrease myriskof heart disease.Iknow these changesinclude
having
• lessgoodcholesterol(HDL) thatmayprotect againstheartdisease andmore badcholesterol (LDL) thatmay
increase the riskof heart disease
• higherbloodpressure
• more depositsof fataroundmy internal organs
I knowthat my riskof heart disease ishigherif people inmyfamilyhave hadheartdisease,if Iamoverweight,
or if I smoke.
I knowthat I shouldhave periodicheart-healthcheckupsforaslongas I take testosterone.Iknow thatmeansI
mustwatch my weightandcholesterollevelsandhave themcheckedbymyclinician.
I knowtestosterone candamage the liverandpossiblyleadtoliverdisease.Iknow Ishouldbe checkedfor
possible liverdamage foraslongas I take testosterone.
I knowtestosterone canincrease myredbloodcellsandhemoglobin.Iknow thatthe increase isusuallyonlyto
whatis normal for a man.I know that wouldhave nohealthrisks.ButI alsoknow that a higherincrease can
cause problemsthatcan be life-threatening.These problemsincludestroke andheartattack.That’s whyI know
I needtohave periodicbloodchecksforas longas I take testosterone.
I knowthat takingtestosteronecanincrease myriskfordiabetes.Itmaydecrease mybody’sresponse toinsulin,
cause weightgain,andincrease depositsof fataroundmyinternal organs.Iknow that I shouldhave periodic
checksof mybloodglucose foras longas I take testosterone.
I knowmy bodycan turn testosterone intoestrogen.AndIknow thatno one knowsif that couldincrease the
riskof cancersof the breast,the ovaries,orthe uterus.

4. 4
I knowtakingtestosterone canthinthe tissue of mycervix andthe wallsof myvagina.Thiscan leadto tears or
abrasionsduringvaginal sex play.Iknowitdoesn’tmatterif mypartneris a womanor a man. Thisraisesmy risk
of gettingasexuallytransmittedinfection,includingHIV.Iknow Ishouldspeakfranklywithmyclinicianabout
my sex life tolearnthe bestwaystopreventandcheck forinfections.
I knowthat testosterone cangive me headachesormigraines.Iknow thatit’sbestto talkwithmy clinicianif I
getthema lotor if the painisunusuallysevere.
I knowthat testosterone cancause emotionalchanges.Forexample,Icouldbecome more irritable,frustrated,
or angry. I knowthatmy cliniciancanhelpme findresourcestoexplore andcope withthese changes.
I knowthat testosterone causeschangesthatotherpeople will notice.Some transgenderpeoplehave
experiencedharassment,discrimination,andviolencebecause of this.Othershave lostthe supportof loved
ones.I knowmycliniciancanhelpme findadvocacyand supportresources.
Prevention ofMedical Complications
I agree to take testosterone asprescribed.AndIagree totell myclinicianif Ihave any problemsoram unhappy
withthe treatment.
I knowthat the dose and type of medicationthat’sprescribedforme maynot be the same as someone else’s.
I knowI needperiodicphysical examsandbloodteststocheckforany side effects.
I knowtestosterone caninteractwithotherdrugsandmedicines.These include alcohol,dietsupplements,
herbs,otherhormones,andstreetdrugs.Thiskindof interactioncancause complications.Iknow thatIneedto
preventcomplicationsbecausetheycanbe life-threatening.That’swhyIneedtobe honestwithmyclinician
aboutwhateverelse Itake.Ialsoknowthat I will continue togetmedical care here nomatterwhat I share
aboutwhat I take.
I knowthat itcan be riskyfor anyone withcertainconditionstotake testosterone.Iagree tobe evaluatedif my
clinicianthinksImayhave one of them.Thenwe will decide if it’sagoodideato start or continue using
testosterone.
I knowthat usingtestosteronetoappearmanlierisanoff-labeluse. Iknow thismeansitisnotapprovedbythe
government.Iknowthatthe medicine anddose thatisrecommendedforme isbasedonthe judgmentand
experience of the healthcare provider.
I knowthat I can choose to stoptakingtestosterone atanytime.Iknow that if I decide todo that,I shoulddoit
withthe helpof my clinician.Thiswillhelpme make sure there are nonegative reactions.Ialsoknowmy
clinicianmaysuggestthatI cut the dose or stop takingitat all if certainconditionsdevelop.Thismayhappenif
the side effectsare severe orthere are healthrisksthatcan’tbe controlled.

5. 5
Alternatives
There are alternativestousingtestosterone tohelppeople appearmanlier.If youare interestedinalternativesto
testosterone therapy,talktoyourclinicianaboutyouroptions.
Our signatures belowconfirmthat
• My clinicianhastalkedwithme about
› the benefitsandrisksof taking testosterone
› the possible orlikelyconsequencesof hormone therapy
› potential alternative treatments
• I understandthe risksthatmaybe involved.
• I knowthatthe informationinthisformincludesthe knowneffectsandrisks.Ialsoknow thatthere may be
unknown long-termeffectsorrisks.
• I have hadenoughopportunitytodiscusstreatmentoptionswithmyclinician.
• All of myquestionshave beenansweredtomysatisfaction.
• I believe Iknowenoughtogive informedconsenttotake,refuse,orpostpone testosteronetherapy.
Basedon all thisinformation
_____ I wantto begintaking testosteone.
_____ I do notwishto begintaking testosterone atthistime.
PatientSignature Date
Signature of Parentor GuardianDate
Prescribingcliniciansignature Date
Your healthisimportanttous. If you have anyquestionsorconcernsplease call
us at (203) 852-9525. We are happyto helpyou.