Knee, Elbow, Shoulder.
Injection with Lidocaine and methylprednisone. 
Limited to 4 injections/12 months. 
Not guaranteed to be helpful but many people do feel better after an injection. 

Risks and Benefits of Joint Injections
Joint injections, particularly those involving corticosteroids, are used to manage pain and inflammation in various musculoskeletal conditions. The benefits include:

• Pain relief: Corticosteroid injections effectively reduce inflammation and alleviate pain in joints affected by conditions like arthritis or bursitis.
• Improved mobility: By reducing inflammation, these injections can enhance joint mobility and function.

However, there are also risks associated with joint injections:

• Infection: Although rare, infection is a potential complication if proper sterile technique is not followed.
• Tendon rupture: This is more likely with injections around tendons like the Achilles tendon.
• Cartilage damage: Long-term use of corticosteroids may lead to cartilage degradation.
• Post-injection flare: A temporary increase in pain and inflammation can occur after injection.
• Skin and soft tissue effects: These include atrophy, depigmentation, and bruising.

Key Considerations

• Technique: Proper injection technique is crucial to minimize risk
• Patient selection: Injections should be avoided in certain conditions, such as active infections or severe osteoporosis.
• Monitoring: Patients should be monitored for potential side effects post-injection.

For existing patients this would be discounted by 1/3. 

Includes: CBC with Diff, Comprehensive Metabolic Panel, Estradiol, Lipid Panel, PSA (Total), Testosterone Free & total with SHBG, TSH, T4, T3, thyroid Peroxidase abs, B12, Vitamin D, Cortisol, FSH and LH.

Access 9862, 2 SST, 1 lavender

Includes syringes, alcohol swabs, medication dispensed at the office is testosterone cypionate not to exceed 200mg/week. 
Excludes labs. 
Monthly Fee after initial consultation.
Provides access to provider between visits for common health issues; for example treatment of a sinus infection, or antiviral for cold sores. 

Direct Primary Care (DPC) is a healthcare model that offers an alternative to traditional fee-for-service insurance billing. In DPC, patients pay their healthcare providers a flat monthly fee, which covers a broad range of primary care services. This model emphasizes a direct financial relationship between patients and their primary care providers, eliminating the need for insurance billing for routine services.
Key Features of Direct Primary Care:

1. Flat Monthly Fee: Patients pay a consistent monthly fee, which typically covers all or most primary care services, including office visits, consultations, and basic lab work interpretation.
2. No Insurance Billing: DPC practices do not bill insurance companies for services. This reduces administrative overhead and allows providers to focus more on patient care.
3. Enhanced Access: Patients often have better access to their providers, including same-day or next-day appointments, longer visits, and direct communication via phone or email.
4. Personalized Care: With fewer patients per provider, DPC allows for more personalized and comprehensive care, fostering stronger patient-provider relationships.
5. Transparent Pricing: Costs are clear and predictable, with no hidden fees or surprise bills.

Advantages Over Traditional Insurance-Based Models:

• Cost-Effectiveness: By eliminating insurance middlemen for primary care, DPC can reduce overall healthcare costs for patients, especially those who require frequent visits or have chronic conditions.
• Reduced Administrative Burden: Providers spend less time on paperwork and more time on patient care, improving job satisfaction and patient outcomes.
• Improved Patient Satisfaction: Patients often report higher satisfaction due to better access, more time with their providers, and a more personalized approach to care.
• Focus on Preventive Care: The model encourages preventive care and early intervention, which can lead to better long-term health outcomes.

While DPC offers many benefits, it may not be suitable for everyone. It typically does not cover specialist care, hospitalizations, or emergency services, so patients often need a high-deductible insurance plan for catastrophic events. However, for primary care needs, DPC can provide a more accessible, affordable, and patient-centered approach compared to traditional insurance models.

Initial visit is 150.00. Then the following month the monthly charges are initiated. Pay in advance for additional discounts. 

Includes medication delivered to your home, Excludes labs. Due to increased dose with absorption through skin, the medication costs more. 
Membership provides access to practitioner between visits for common health problems such as evaluation of a URI. 

Sermorelin is a synthetic peptide that stimulates the secretion of growth hormone (GH) from the pituitary gland. Growth hormone plays a crucial role in muscle growth and repair, as well as fat metabolism. By increasing GH levels, Sermorelin can potentially enhance muscle mass and strength. Additionally, GH can help with recovery and may contribute to a more youthful appearance.
While Sermorelin itself does not directly build muscle, its ability to stimulate GH release can lead to increased levels of insulin-like growth factor-1 (IGF-1), a hormone that promotes muscle hypertrophy and is involved in the regulation of muscle growth. However, it's important to note that the use of such substances for performance enhancement is often regulated and may be prohibited in competitive sports. Use of Semorelin is off label. It ?is not covered by insurance and ?provider will request you to sign an indemnification clause. Long term risks remain to be seen. 

Pay for 3 months for additional savings. 

3mg/ml multidose vial. Each vial has 5ml. 
Dose is 0.3mg (10 units) sc before bed x 28 days.

NAD+ supplementation is said to have positive effects on heart health, muscle function, enhance aerobic capacity, improve insulin sensitivity and brain health. It is considered an anti-aging supplement. 

Dosing suggestion is 50mg (0.25ml) SC weekly x 1 month then
100mg (0.5ml) sc weekly.

After this you can increase to twice a week. 

Each vial has 400mg/2ml. 

Vitamin B12 supplements: Role in the Body

Vitamin B12 (cobalamin) is essential for red blood cell formation, nerve function, and DNA production. Vitamin B-12 deficiency is not common in the U.S. However, people who follow a vegetarian or vegan diet might be prone to deficiency because plant foods don't contain vitamin B-12. Older adults and people with digestive tract conditions that affect absorption of nutrients also are susceptible to vitamin B-12 deficiency.

Left untreated, a vitamin B-12 deficiency can lead to anemia, fatigue, muscle weakness, intestinal problems, nerve damage and mood disturbances.

• Fatigue and weakness. 
• Headaches and dizziness. 
• Pale or yellow skin. 
• Nerve problems such as tingling or numbness. 
• Cognitive issues, including memory problems and difficulty thinking. 
  
  These symptoms can develop slowly and may worsen over time if not addressed.

Recommended Dosage: The recommended daily intake for adults is 2.4 micrograms (mcg). Supplements often contain higher doses, typically ranging from 50 to 1,000 mcg. 

Food Sources: Natural sources include poultry, meat, fish, and dairy products. 

Potential Side Effects: Vitamin B12 is generally safe, but excessive intake can lead to side effects such as headaches or nausea. Healthline
Vitamin B12 Dosage. This is why it is important to have a lab assessment. 

Includes: CBC, comprehensive metabolic panel, lipid panel, Iron, Total, Ferritin, Estradiol, Progesterone, Testosterone Free and total with SHBG, FSH, LH, DHEA-S, TSH.

Access panel 195E, 2 SST, 1 lavender

????LEVEL 3 – THRIVE (Concierge Hormone & Wellness Care)
Best for: Complex or persistent symptoms, or patients who want comprehensive, hands?on support
Includes:

• Monthly telehealth visits with extended time
• Advanced bioidentical hormone management with more frequent adjustments
• Included lab testing through Access Medical Labs (routine hormone and wellness panels per protocol)
• Preferred pricing access to peptides when clinically appropriate
• Priority secure messaging
• Limited primary care services, including:
  • Acute visits for simple issues
  • Prescription refills for non?controlled maintenance medications
  • Care coordination with outside providers
• Insurance navigation support when applicable

Focus: High?touch, all?inclusive hormone and wellness care with fewer barriers and faster adjustments.
Investment: $199/month.

$250 if including 2 hormones from compounding pharmacy.

Skin lesion removed and sent to pathology. Includes anesthetic injection and dressing post removal. Provider will coordinate referral for larger resection if malignant. 

If it is black or gray, dont spray. It could be melanoma.

Initial Consult with dermoscopy is $150. This is the additional fee for removal of skin lesion and sent to pathology.

Phone, in person or telehealth f/u doing well with medication refill. ?

This is the first consultation. Labs have been done prior and are reviewed, collection and confirmation of past medical history is documented. Plan of care is developed. Often appointment lasts 90 minutes.

Initial visit with goals of care planned, collection of past history, examination if needed.  Review of membership options available to men including HRT, peptides, weight loss, erectile dysfunction, fertility and hair loss treatment options. Plan of care development. If planning TrT note this is a controlled substance and may require an annual in person face to face visit. Can provide good faith estimate of a monthly membership inclusive of labs and medications. 

Initial evaluation includes past history, development of plan of care. 
Good faith estimate provided would include attentive care plan until you are on your way to a healthier eating pattern and exercise program.

After your intial evaulation this is a follow up visit to check vital signs, adjust medications and exercise program. Up to 30 minutes with provider. Weight check, emotional support provided. 

Women are complicated. Moon phases, etc. Premenopausal evaluations take a long time. This is a 1.5 hour slot to really get to the nitty gritty.

Hormonal imbalances can disrupt every aspect of your life, from mood to energy levels to overall health. Now is the time to say goodbye to: 

• Low Libido
• Hot Flashes
• Night Sweats
• Weight Gain
• Irritability
• Sleep disturbances
• vaginal dryness
• mood swings
• irregular periods
• joint pain
• loss of hair
• dry skin
• brain fog
• and more...

This is your chance to regain control over your health and well-being. Together, we can create a treatment plan that helps you feel like yourself again. Start your journey to balance and vitality today. 

Sometimes hormones are NOT the best option for your symptoms. That is OK. I am willing to explore other options as well.

You should have labs prior to this appointment. If you have already had these labs please email these to me via the portal or fax/mail to the office. 

We do offer Dutch Testing, saliva testing, in addition to traditional labs.

Don't have insurance? I can pass along my lab savings to you using my Access lab account. 

15-30 minute visit

Hormone pellet with lab template

Cryotherapy is used to remove several types of skin lesions, including:

• Warts: Common, plantar, and anogenital warts can be effectively treated with cryotherapy.
• Seborrheic keratoses: These benign growths are commonly treated with cryosurgery, especially when multiple lesions are present.
• Actinic keratoses: These precancerous lesions can be destroyed using cryotherapy.
• Solar lentigines: Also known as sun spots, these can be treated with cryosurgery.
• Molluscum contagiosum: A viral infection causing small bumps on the skin, which can be treated with cryotherapy.
• Skin tags: Benign growths that can be removed using cryosurgery.

Cryotherapy involves freezing the lesion with liquid nitrogen, causing the affected tissue to die and eventually fall off.

This is for up to 14 lesions. If there are more you may have additional fees. 

If your skin lesion is black or gray, don't spray. This needs to be removed shave method. If positive for melanoma you will need larger resection. 

Up to 60 minutes with provider monthly, plus the medication phentermine shipped to your home. 

This is for medication only. Semaglutide is ?compounded with pyridoxine to assist with nausea.
This is shipped to your home. Includes syringes and alcohol swabs. 
Source is Southend Pharmacy.
Price includes Shipping

For established patients, this is a brief visit for when things are going well. Taking about 15 minutes it is an annual or biannually followup for medication refills. Includes interpretation of bone density if it has been done in since the last visit. Interpretation of applicable labs. Review of medications and risks. 

For established patients, this is a lengthier visit for when things are not going well. Taking about 30 minutes, there has been a change of plan and may require work behind the scenes with insurance companies in addition to the time spent with you exploring risks associated with alternative plans. Visit still includes interpretation of bone density if it has been done in since the last visit. Interpretation of applicable labs. Review of medications and risks. 

Hormone Pellets are a form of hormone replacement therapy (HRT) that involves implanting small pellets under the skin to release hormones, typically estradiol or testosterone, into the bloodstream. General benefits and risks associated with HRT can be applied to this form of therapy.
This is the cost per insertion. This is often four times a year. 

Benefits of Hormone Pellets

• Symptom Relief: Hormone pellets can alleviate symptoms of menopause or low testosterone, such as hot flashes, night sweats, and decreased libido.
• Convenience: Pellets provide a steady release of hormones over several months, eliminating the need for daily medication.
• Potential for Improved Bone Density: Similar to other forms of HRT, hormone pellets may help maintain bone density.

Risks of Hormone Pellets

• Increased Risk of Blood Clots: Hormone therapy can increase the risk of blood clots, which may lead to conditions like deep vein thrombosis or pulmonary embolism.
• Cardiovascular Risks: There is an increased risk of heart attacks and strokes associated with certain types of HRT.
• Breast Cancer Concerns: Combined estrogen and progestin therapy has been linked to an increased risk of breast cancer.
• Local Complications: Pellet insertion can lead to local reactions or infections at the site of implantation.

Hormone Pellets are not FDA approved and are obtained from licensed 503B compounding pharmacies. Preferred pharmacy is Belmar. Hormone pellet placement is considered elective, and is not covered by insurance because alternative methods exist that are FDA approved. Note there is currently no FDA approved form of Testosterone for women, yet women have 7x more testosterone than estrogen at her peak in life.  

Price includes medication, supplies and access to Duke for up to 60 minutes monthly for other health needs. By paying in advance you do get a discount off monthly cost. 

Schedule a time to speak to provider to ensure this is the best fit for you. Also an opportunity to gather symptoms for lab evaluation.

Access to Duke up to 60 minutes monthly includes med shipped to your home. Prepay 3 months saves. 

Don't have time to get an honest opinion about your Osteopenia? How worried should you be? Here you can book a time for Elizabeth Duke, NP to review your bone density results, health history, your history of falls, diet and exercise. You will need to provide your bone density results and answer questions about your habits. Then within 72 hours you will obtain a tailored care plan based on the information you have provided. 

• Fracture risk assessment
• Nutrition evaluation and guidance
• Lifestyle modifications
• Education
• Fall risk assessment
• Safe exercise program tailored to your level of fitness.
• Prevent spinal deformity
• Prevent frailty

This is an asynchronous visit. In person appointments are also available via telehealth or at the office in Bangor.

Join Our Informative Class: "Bone Health Strategies"

Date: 5/26/25 and 5/27/25 at 6-730pm
Location: Online


 Instructor: Elizabeth Duke, NP

Are you confused about the conflicting information regarding Osteoporosis and Osteopenia? Calcium and Vitamin D? You're not alone! With so much debate and controversy, it's hard to know what to believe. Our comprehensive class will help you navigate through the noise and provide you with reliable, evidence-based information.

What We Will Cover:
DAY 1: 
BONE HEALTH 101

PREVENTION MEASURES

DAY 2:
 CALCIUM, PROTEIN, AND BONE HEALTH MEDICATIONS AND EXERCISES

GADGETS

• Interactive Q&A Session:

Get your questions answered by an experienced Family Nurse Practitioner. 

Why Attend?

• Gain clarity on the latest research and guidelines 
• Learn how to make informed decisions about your health 
• Empower yourself with knowledge from a trusted healthcare professional 

Registration Information:
Cost: $ 100 for both days.

 Don't miss this opportunity to enhance your understanding of Bone Health.  Secure your spot today and take a step towards better health!

For more information, contact Elizabeth Duke, NP at 207-326-2995.

Direct Primary Care (DPC) is a healthcare model that offers an alternative to traditional fee-for-service insurance billing. In DPC, patients pay their healthcare providers a flat monthly fee, which covers a broad range of primary care services. This model emphasizes a direct financial relationship between patients and their primary care providers, eliminating the need for insurance billing for routine services.
Key Features of Direct Primary Care:

1. Flat Monthly Fee: Patients pay a consistent monthly fee, which typically covers all or most primary care services, including office visits, consultations, and basic lab work interpretation.
2. No Insurance Billing: DPC practices do not bill insurance companies for services. This reduces administrative overhead and allows providers to focus more on patient care.
3. Enhanced Access: Patients often have better access to their providers, including same-day or next-day appointments, longer visits, and direct communication via phone or email.
4. Personalized Care: With fewer patients per provider, DPC allows for more personalized and comprehensive care, fostering stronger patient-provider relationships.
5. Transparent Pricing: Costs are clear and predictable, with no hidden fees or surprise bills.

Advantages Over Traditional Insurance-Based Models:

• Cost-Effectiveness: By eliminating insurance middlemen for primary care, DPC can reduce overall healthcare costs for patients, especially those who require frequent visits or have chronic conditions.
• Reduced Administrative Burden: Providers spend less time on paperwork and more time on patient care, improving job satisfaction and patient outcomes.
• Improved Patient Satisfaction: Patients often report higher satisfaction due to better access, more time with their providers, and a more personalized approach to care.
• Focus on Preventive Care: The model encourages preventive care and early intervention, which can lead to better long-term health outcomes.

While DPC offers many benefits, it may not be suitable for everyone. It typically does not cover specialist care, hospitalizations, or emergency services, so patients often need a high-deductible insurance plan for catastrophic events. However, for primary care needs, DPC can provide a more accessible, affordable, and patient-centered approach compared to traditional insurance models.

This is where we prepay 3 months at a time, Autopay every 3 months and save $120/year.

Dried Urine Test for Comprehensive Hormones.

Placement of hormone pellets under the skin to be slowly released to control hormonal symptoms. Typically done 4 x per year and just pellet insertion is $500 per visit for procedure, and interpretation of your labs quarterly. This is discounted significantly into a monthly payment plan to make this affordable for you without needing to obtain "Care Credit" or Cherry credit services. Practitioner is financing you at Integrated Wellness. Source of Pellets is usually Belmar Pharmacy but sometimes due to supply issues could be obtained from another compounding pharmacy as needed. Combinations for females include Estradiol, Testosterone and Progesterone. This procedure is usually not covered by insurance. Risks include risk of infection

Pellet placement is done in the office. Area is numbed with lidocaine, small incision made then sterile pellets are placed with a trochar. Incision is so small not needing a suture. Pressure bandage is applied. Might cause small scar. Place it and forget it. Great for people who cannot remember to take medications. 

1. Services Provided
Integrated Wellness agrees to provide the following hormone health care services to the Client on a monthly basis:

• Comprehensive hormone health assessment
• Personalized hormone optimization plan for progesterone, estrogen, testosterone pellet therapy. 
• Up to 6 visits per year for common health problems in addition to hormone health problems
• Interpretation of laboratory testing 
• Up to 4 implantations of bioidentical hormone pellets annually.

2. Payment Terms

The Client agrees to pay a monthly fee of $135 for the services outlined in this Agreement. Payment is due on the same day of each month and can be made via Credit card or debit card.

3. Term and Termination

This Agreement shall commence on [Start Date] and shall continue on a month-to-month basis until terminated by either party. Either party may terminate this Agreement with 30 days written notice.

4. Cancellation and Refund Policy

The Client may cancel services at any time with 30 days written notice. Refunds for any prepaid services will be prorated based on the cancellation date.

5. Confidentiality

Integrated Wellness agrees to maintain the confidentiality of the Client's personal and medical information in accordance with applicable laws and regulations.

6. Limitation of Liability

Integrated Wellness shall not be liable for any indirect, incidental, or consequential damages arising out of or related to the services provided under this Agreement.

7. Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of Maine.

8. Entire Agreement

This Agreement constitutes the entire agreement between the parties and supersedes all prior agreements or understandings, whether written or oral, relating to the subject matter hereof.

Skin Cancer is a real issue in the state of Maine. Melanoma is on the rise; Maine has the 12th highest incidence in the country. Dermoscopy can help with earlier detection of melanoma as well as other types of skin cancer including squamous cell carcinoma and basal cell carcinoma.

• Asymmetry: One half of the mole looks different from the other half.
• Border: The edges of the mole are uneven, irregular, or poorly defined.
• Color: The color of the mole is not uniform and may include shades of brown, black, tan, red, white, or blue.
• Diameter: The mole is larger than 6 mm (1/4 inch) or about the size of a pencil eraser.
• Evolving: The mole or spot is changing in size, shape, color, or thickness over time.

When in doubt, check it out. 
If you have a skin lesion worrisome for melanoma, provider can remove it and send for pathology and expedite referral to dermatology. This is subject to additional fee.
Service includes giving you a photo you can share with your pcp or dermatologist or referral to a dermatologist if needed. 

? Glutathione Injection Overview
Glutathione is the body’s master antioxidant, used in every cell to reduce oxidative stress, detoxify, and support immune and mitochondrial function. Injectable glutathione delivers it directly into circulation, bypassing digestion.
? Potential Benefits
1. Antioxidant & Cellular Protection

• Reduces oxidative stress and free radical damage
• Supports healthy aging and cellular repair

2. Detoxification Support

• Helps regenerate liver detox pathways (Phase II)
• Sometimes used adjunctively in toxin or medication overload (under medical supervision)

3. Skin Benefits

• Can reduce melanin production
• Sometimes used for skin brightening or evening of tone(Evidence is mixed; results vary.)

4. Immune Support

• Helps regulate immune response in chronic inflammation

5. Mitochondrial & Energy Support

• May support ATP production by reducing oxidative load

6. Neurological Support

• Sometimes used in functional medicine to help oxidative stress related to neurological conditions

? Advanced antioxidant support
? Helps combat seasonal stress
? Supports natural detox processes
? Assists with post-holiday recovery
? Supports a brighter, more refreshed look
? Helps support immune resilience


Legal Notice: Glutathione injections are not FDA-approved for skin lightening or whitening, and wellness uses are not evaluated by the FDA. All services are elective and should be discussed with a qualified healthcare professional.

Hormone Pellets are a form of hormone replacement therapy (HRT) that involves implanting small pellets under the skin to release hormones, typically estradiol or testosterone, into the bloodstream. General benefits and risks associated with HRT can be applied to this form of therapy. They are often inserted 3-4 times per year.

Benefits of Hormone Pellets

• Symptom Relief: Hormone pellets can alleviate symptoms of low testosterone.
• Convenience: Pellets provide a steady release of hormones over several months, eliminating the need for daily medication.
• Potential for Improved Bone Density: Similar to other forms of HRT, hormone pellets may help maintain bone density.

Risks of Hormone Pellets

• Increased Risk of Blood Clots: Hormone therapy can increase the risk of blood clots, which may lead to conditions like deep vein thrombosis or pulmonary embolism.
• Cardiovascular Risks: There is an increased risk of heart attacks and strokes associated with certain types of HRT.
• Breast Cancer Concerns: Combined estrogen and progestin therapy has been linked to an increased risk of breast cancer.
• Local Complications: Pellet insertion can lead to local reactions or infections at the site of implantation.

Lab is sent to access Medical lab. This would include mens health basic panel which includes  Free and total Testosterone, psa, CBC, CMP, SHBG

LEVEL 1 – BALANCE

Best for: Mild to moderate symptoms or patients early in hormone therapy
Includes:

• Telehealth visit every 3 months up to 45 minutes.
• Symptom?focused hormone review and adjustments
• Prescriptions through standard pharmacies (insurance may apply)
• Lab review as indicated
• Secure messaging for brief questions
• Receipt will include ICD 10 codes for potential reimbursement from FSA or HSA. 

What is not included: 

• Extensive messaging, medications, lab costs. 
• Cannot guarantee coverage of labs. 
• Concerns that are NOT hormone related.

Focus: Relief of common symptoms such as hot flashes, sleep disruption, mood changes, or low energy—without intensive follow?up.
Investment: $79/month

LEVEL 2 – OPTIMIZE
Best for: Ongoing menopause or perimenopause symptoms needing regular fine?tuning
Includes:

• Monthly visits (20–30 minutes) with initial visit being 1 hour. 
• Active hormone titration based on symptoms and labs
• Interpretation of labs
• Access to bioidentical hormone therapy when appropriate for additional charges.
• Prescriptions through standard or compounding pharmacies
• Secure messaging between visits
• Medication management and refills with possible monthly titration
• Receipt will include ICD 10 codes for potential reimbursement from FSA or HSA. 

Focus: Getting hormones dialed in so you feel consistently better—month by month.
Investment:

• Months 1–6: $149/month
• Month 7+: $99/month once symptoms are stable

What is not included: 

• Extensive messaging, medications, lab costs. 
• Cannot guarantee coverage of labs. 
• Concerns that are NOT hormone related. 
• This is not primary care.