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The Marion Gluck Clinic

Background

At the Marion Gluck Clinic, we take your privacy and the security of your personal data extremely seriously. In order to offer you the best possible treatment, we may need to store, process and from time to time share your personal data with third parties. 

Declaration

  • I have received a full explanation of the nature of the treatment(s) to be provided to me by my doctor.
  • I understand that my doctor is bound by and will always adhere to the General Medical Council Code of Conduct .
  • Under the provisions of the Data Protection Act 1998 and GDPR, I understand that my doctor needs my consent to keep information about me and my health on the practice computer system.
  • I understand that the information that my doctor 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 Marion Gluck Clinic may hold, update and use my information for the purposes of monitoring and improving that service. It may also anonymize 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 circumstance’s other doctors at The Marion Gluck 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 Marion Gluck Clinic, if I wish to alter my consent.
  • I understand that if I require a chaperone for my consultation, I can speak with the reception team to arrange this.

Informed Consent for Personalised Bio-identical Hormone Replacement Therapy

Background

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.

Bioidentical hormones have the exact same chemical structure with your own hormones. Your BHRT 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 PMS­like 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 a given situation.

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. Estrogen 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: estrogens (estradiol and estriol), progesterone, testosterone and dehydroepiandrosterone (DHEA). Thyroid hormones (thyroxine and triiodothyronine) may also be prescribed depending on your needs.

Risks

Studies showed that using estrogen 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 estrogen and progestins (synthetic progesterone) increases the risk of breast cancer over estrogen alone.

The risk of breast cancer depends on a number of 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.

We monitor our patients regularly and our 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.

Declaration

  • I understand that there are benefits of this treatment if successful, and I also understand that the doctor cannot be sure that the treatment will fully help me.
  • I have discussed the reasons for taking hormones with my doctor and understand why he/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 Bio­identical Hormone Replacement Therapy (BHRT) have been explained to me, and I have had the opportunity to ask any questions concerning this treatment.
  • I understand that as my prescription is personalised specifically for me, and unless directed otherwise, the doctor will send this prescription directly to the Specialist Pharmacy, who will compound the medication to the standards required.
  • I understand that I am responsible for contacting the relevant provider to order and pay for my medication.

Terms and Conditions of Payment

Background

Upon booking your appointment we will require your card details which will be securely stored on file. Initial appointment payments will be made prior to booking the appointment. All other appointment payments are due at the time of your consultation. You will be invoiced via email after your treatment and payment will be taken from your card on the day of your appointment. No payment will be taken without you being notified beforehand. Failure to make payment within 30 days of the invoice date may result in the matter being referred to our Debt Collection Agents whose charges may be added to the invoice amount.

Declaration

  • Marion Gluck Clinic is the trading name of Gluck International Ltd., a company wholly owned by Gluck International Ltd, a company in which some of the practicing doctors 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 doctor if you do not wish anyone to be present for your consultation.
  • Only formal requests (form available on our website) would be accepted for retrieval of this data to external sources. The Marion Gluck 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. These images may be anonymized and used for training purposes.
  • A copy of this patient information record and patient consent form is retained on your patient file, which is kept electronically within The Marion Gluck Clinic.
  • Please be aware that we may share personal information with external companies, with your written consent. This can include providers such as: TDL, Genova Diagnostics, Specialist Pharmacy, and your next of kin.
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