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Rooted Health Consent Forms

Transition From Insurance
Form

Please complete the enrollment form below. Our clinical team will review your application for appropriateness before final membership acceptance.

Patient Forms & Consents

As a cash-pay direct primary care practice, we want every patient to fully understand the care, costs, and consents involved. Please complete all sections below before your first visit.

Rooted Health Hormones

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Home address

Hormone Consent Form

Hormone Therapy Informed Consent

Arkansas APRN Practice Note (Ark. Code § 17-87-310): LaDonna Walker, MSN, APRN, FNP-BC practices under a collaborative practice agreement with Abrar Ashraf Khan, MD per Arkansas law. All prescriptions are issued by LaDonna Walker within her FNP scope of practice. Most hormone therapy is prescribed off-label for adult wellness optimization.

Scope — Treatments Covered

Testosterone (injections, pellets, cream, oral troches), estrogen (Bi-Est, estriol), progesterone, thyroid (NDT, T3/T4), DHEA, and related compounded hormone medications prescribed at Rooted Health. Labs are required before initiation and at follow-up intervals.

Potential Benefits

Hormone therapy may improve energy, libido, mood, sleep quality, body composition, cognitive function, bone density, skin quality, and overall wellbeing. Results are individual and not guaranteed. Benefits typically emerge at 6–12 weeks.

Risks by Therapy Type

  • Testosterone: Acne, hair thinning, mood changes, elevated hematocrit, suppression of natural hormone production, reduced fertility, testicular atrophy (men), clitoral growth/voice changes (women at high doses), cardiovascular risk in predisposed patients.

  • Estrogen: Blood clot (DVT/PE) risk, stroke, breast tenderness, nausea, fluid retention, potential increased cancer risk with prolonged use.

  • Progesterone: Drowsiness, bloating, mood changes, breast tenderness.

  • Thyroid (NDT): Palpitations, anxiety, insomnia, weight loss if over-replaced; osteoporosis risk with long-term over-replacement.

  • Pellets: Insertion site bruising, infection, or extrusion; inconsistent absorption; dose cannot be reduced once implanted for the treatment cycle.

Contraindications

Do NOT start hormone therapy if you have: active or history of hormone-sensitive cancer (breast, uterine, prostate, ovarian), untreated or active DVT/PE or clotting disorder, active liver disease, uncontrolled hypertension or cardiovascular disease, pregnancy or breastfeeding.

You are required to disclose all medical conditions truthfully. Failure to disclose may affect the safety and appropriateness of your treatment.

Lab Requirements

Baseline labs are required before any hormone therapy is initiated. Follow-up labs are required every 3–6 months during active therapy or as clinically directed. Treatment may be paused or discontinued if labs are not completed as scheduled. Pellet patients must complete monitoring labs before each subsequent insertion.

Do you have any of the contraindications listed above?
Yes
No
Which hormone therapy treatments are you consenting to?
Birthday
Month
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GLP-1 Weight loss
Consent Form

GLP-1 / Weight Loss Therapy Consent

Compounding Pharmacy Notice (Arkansas Board of Pharmacy)

GLP-1 medications at Rooted Health are compounded from licensed 503A compounding pharmacies. These are NOT the same as commercially manufactured Ozempic®, Wegovy®, Mounjaro®, or Zepbound®. Compounded medications are legally prescribed on a patient-specific basis. Quality, potency, and safety data may differ from commercial products. Only use medications dispensed directly by Rooted Health or our designated pharmacy partners.

In-Clinic Injection vs. Take-Home Bottle

  • In-clinic single injections are administered at each visit during your initial dosing phase while we confirm your response and optimal dose. Pricing is per injection as shown on your treatment plan.

  • Take-home bottles are dispensed for self-administration once you and your provider agree the medication is working well at a stable dose. Bottles include syringes and injection training. Take-home bottle pricing is separate from in-clinic injection pricing.


    Common Side Effects


  • Very common: Nausea, decreased appetite, constipation, diarrhea — typically improve within 2–4 weeks of dose initiation or increase

    Common: Fatigue, headache, dizziness, injection site reactions, heartburn, belching


    Notable: Temporary hair thinning (telogen effluvium); muscle mass loss if protein intake is insufficient; gallstone formation with rapid weight loss



    Seek Immediate Medical Attention if You Experience:


    Severe or persistent abdominal pain (possible pancreatitis), vision changes, sustained rapid heart rate, signs of allergic reaction (hives, difficulty breathing, facial swelling), or inability to tolerate fluids (dehydration risk).


    Contraindications — Do NOT use if:



    Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2)

    History of pancreatitis

    Pregnancy or planning to become pregnant — discontinue at least 2 months before attempting conception

    Severe renal impairment (eGFR <15) or end-stage renal disease

    Severe hepatic impairment.


Birthday
Month
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Aesthetics
Consent Form

Aesthetics & Injectables Consent

Rooted Health — LaDonna Walker, MSN, APRN, FNP-BC

Arkansas APRN Aesthetic Practice

LaDonna Walker, MSN, APRN, FNP-BC holds certifications from Allergan (Botox Cosmetic), Galderma (Dysport, Restylane), and Empire Medical Training. All injectable and aesthetic procedures are performed within the FNP scope of practice under Arkansas law.

Treatments Covered

  • Botox Cosmetic (onabotulinumtoxinA · Allergan)

  • Dysport (abobotulinumtoxinA · Galderma)

  • Letybo (letibotulinumtoxinA-lltl)

  • Restylane fillers (Contour, Lyft)

  • Sculptra (poly-L-lactic acid)

  • Kybella (deoxycholic acid)

  • LemonBottle fat dissolve

  • PRP face and scalp

  • Microneedling with hyaluronic acid

  • Chemical peels (Illuminize, Vitalize, Rejuvenize)

  • Laser treatments

Aesthetic Membership Discount

Your membership discount applies according to your tier's published benefits (5%, 10%, or 20%). It applies to aesthetic procedures listed above. It does NOT compound with other offers and is applied at checkout. The discount does not apply to membership dues, enrollment fees, or per-quote services.

Neuromodulator Risks (Botox / Dysport / Letybo)

  • Temporary bruising, swelling, redness at injection sites (usually resolves 24–72 hrs)

  • Headache, usually resolving within 24 hours

  • Asymmetry or uneven results — may be addressed at 2-week follow-up (touch-ups billed separately)

  • Eyelid or brow ptosis (drooping) — rare, temporary, resolves as product metabolizes over weeks

  • Spread of toxin beyond injection site — rare at therapeutic doses with trained injector

  • Results last approximately 3–4 months; individual variation applies

Dermal Filler Risks (Restylane / Sculptra / Kybella / LemonBottle)

  • Bruising, swelling, redness, tenderness — may last days to 2 weeks

  • Lumps or irregularities — most resolve spontaneously; provider will advise on massage technique

  • Vascular occlusion (blocked blood vessel): Rare but serious — this practice maintains hyaluronidase on-site and the provider is trained in vascular occlusion management. Seek immediate attention if you notice blanching, severe pain, or skin color changes after filler.

  • Tyndall effect (bluish tint under thin skin) — treatable

  • Infection — rare with proper sterile technique

  • Sculptra: nodule formation possible; follow post-treatment massage protocol

Photo Consent

Before and after photographs are taken for your medical record. You may consent (or decline) to de-identified use of your photos for Rooted Health educational or marketing purposes — no identifying information will be shared. You may change this preference at any time in writing.

Do Not Proceed with Aesthetic Treatment if:

Active infection at or near injection site, known allergy to botulinum toxin products, hyaluronic acid, or lidocaine, pregnancy or breastfeeding, autoimmune neuromuscular disorder (e.g., myasthenia gravis, Lambert-Eaton syndrome) for neuromodulators. Disclose all blood thinners and supplements — treatment may proceed with modified protocol at provider's discretion

I agree I have read this and have no further questions. I agree that I have had a good faith exam.

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Peptides & IV
Consent Form

Peptide Therapy & IV Infusion Consent

Regulatory Notice — Peptide Therapy

Most peptide therapies referenced below are not FDA-approved for the uses described and are prescribed off-label. They are compounded on a patient-specific basis from licensed 503A pharmacies per Arkansas Board of Pharmacy requirements. Clinical evidence varies by peptide. You have the right to ask questions and decline any treatment.

Peptide Therapy — Medications Covered

Sermorelin, CJC-1295/Ipamorelin, BPC-157, TB-500, GHK-Cu, Tesamorelin, NAD+, and related peptide protocols dispensed by licensed 503A compounding pharmacies including Partell Pharmacy, VIOS Pharmacy, Nuvamed, and designated partners.

Peptide Risks & Side Effects

  • Sermorelin / CJC-1295 / Ipamorelin (GH peptides): Injection site reactions, transient water retention, joint aches, headache, increased hunger, flushing, fatigue (usually resolves within 2 weeks of initiation)

  • BPC-157 / TB-500 (Wolverine / Glow Stack): Injection site discomfort, mild nausea, dizziness; long-term human safety data is limited — discuss with your provider.

  • GHK-Cu (Glow Stack): Mild skin flushing or temporary skin changes during initial weeks of use

  • NAD+: Flushing, chest tightness, nausea during infusion — rate-dependent; managed by slowing infusion rate. SQ injections may cause local site reactions.



    IV Therapy — Treatments Covered


    All intravenous infusion therapy including Myers Cocktail, immune support drips, beauty drips, NAD+ IV, and custom IV formulations.


    Vitality+ members receive 1 IV therapy (premade blend) OR 1 NAD+ infusion per month as part of their membership. Additional IVs and NAD+ premium upgrades are billed at the applicable rate. Bring-a-friend IV pricing applies as published.


    IV Therapy Risks



    Bruising, soreness, or phlebitis at IV insertion site

    Allergic reaction — anaphylaxis is rare; emergency equipment and trained personnel are on-site

    Infection at IV site — prevented by sterile technique

    Vitamin toxicity with excessive frequency — provider will advise appropriate intervals



    Arkansas Standard of Care Note


    All IV therapy is ordered and overseen by LaDonna Walker, MSN, APRN, FNP-BC. A medical history and allergy screening is completed before every IV session. Patients with known allergies, renal disease, cardiac conditions, or G6PD deficiency (for high-dose Vitamin C) must inform the provider before each session.

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Member Benefits

• Significant savings on hormone optimization, IV therapy, and aesthetic treatments.

• Priority scheduling and direct provider access via our secure patient portal.

• Comprehensive annual wellness labs and personalized care coordination.

• Exclusive member-only events and early access to new medspa services.

Clinical appropriateness applies; submission does not guarantee acceptance.

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