REJUVE-HEALTH CONSENTS

Purpose

The purpose of this document is to provide written information as of Tuesday, June 28th, 2022 regarding the risks, benefits, and alternatives to the elective procedure of Allograft Cellular Therapy. This is supplementary to the discussion you have had with the doctor, and/or the doctor’s Nurse Practitioner or Physician Assistant (Provider).

It is important you fully understand this information – so please read this document carefully.

Protocols

Allograft Cellular Therapy involves the injection of cells, derived from the umbilical cord of live, healthy- birth babies, via IV or directly into the knee, ankle, shoulder, elbow, wrist, hip, and sacroiliac joints, as well as the facet areas of the lumbar, thoracic or cervical regions (“ACT Injection”). The ACT Injection is made up of a sterile,minimally manipulated, allograft (an allograft is a tissue graft from a donor of the same species as the recipient), derived from an umbilical cord blood, which produces high concentrations of mesenchymal stem cells that as a result of its source bears no antigens, and thus patient rejection is extremely rare. The product is intended for homologous use to replace or supplement damaged or inadequate integumental tissue. Umbilical-cord derived stem cells have been used for years for orthopedic and sports medicine, as well as pain management, podiatry, and wound care. The ACT Injection used by this office for the procedure has been procured from a tissue bank which thoroughly tests the tissue for safety in clinical procedures, and utilizes extensive donor serology test panels and other stringent testing to ensure that the product is free of bacterial and fungal contaminants.

Donor Screening

The donated umbilical cord blood has been determined to be eligible for transplantation by a licensed tissue bank. Review of donor records include donor medical history and risk behavior assessment, medical records, and recent physical examination, and indicate to the tissue bank that the donor is free from risk factors for and clinical evidence of infection due to relevant communicable diseases and other exclusionary disease conditions. All labs performing the tests are registered with the Food and Drug Administration (FDA) and certified to perform testing on human specimens under the Clinical Laboratory Improvement Amendments (CLIA) of 1988 and 42 CFR part 493. An allograft of donated human tissue is deemed qualified for transplantation by a tissue bank if it meets the following criteria:

The results from the donor pre-screening lab tests specify the donor to be free from risk factors and active infections of applicable communicable disease agents and diseases as required by the FDA, and 2) donor results from the pre-screening lab tests must be negative and/or non-reactive for the following applicable communicable disease agents determined by the following: testing for Hepatitis B and C Viruses (HCV/HBV); testing for Human Immuno-Deficiency Viruses Types I and II (HIV I/II AB); Nucleic Acid Testing (NAT) for HIV, and Hepatitis B and C; Core Antibody Testing for Hepatitis B (HBC AB); Testing for Hepatitis B Surface Antigen (HBS AG); Human T-Cell Lymphotropic Viruses I and II (HTLV I/II); and testing for Reactive Plasma Reagin (RPR) (which tests for non-specific antibodies that may indicate a syphilis infection). The tissue bank that provides the injectables our office uses for this procedure has informed this office that the injectable and donor have met the above requirements. By law, the laboratories performing human specimen tests are certified and meet the requirements as determined by the Centers for Medicare and Medicaid (CMS), per CLIA and 42 CFR part 493, and the FDA requires patient records to be properly maintained by storing the allograft ID number (lot number) for purposes of tracking the allograft post treatment.

Indications

The indications for this injection are joint deterioration diseases, arthritic diseases, soft tissue injury and inflammation, autoimmune disorders and/or pain associated with the foregoing.

Description of the Procedure

After the skin surface at the injection site(s) has been thoroughly cleaned, the joint(s)

and/or adjacent muscles and ligaments will be entered with a needle attached to a syringe. At that point, the ACT Injection may either be administered intravenously or injected into my joint space, or the area adjacent to the joint, depending on the Provider’s evaluation and other factors.

Anticipated Outcomes & Benefits

From the ACT Injection procedure, anticipated outcomes and benefits may include relief from pain or pain reduction, increased circulation, increased exercise tolerance, improved pain threshold, increased range of motion, improved joint function, or other structural improvements (collectively, “ Results”). As with any medical procedures, Results from the ACT Injection cannot and are not guaranteed. Moreover, multiple treatments may be necessary to achieve any or optimal Results. Post injection, a mild inflammatory reaction is expected – and desired – in order to facilitate the healing process.

Adverse Reactions

Limited adverse clinical reactions to ACT Injection product have been reported, but it is not impossible for an adverse reaction to happen. If any signs of infection or reaction occur, contact your Provider Immediately. Adverse reactions or outcomes that potentially involve the use of this tissue product must be reported.

Risks

The ACT Injection procedure to which I am consenting is one or more injections of joints or surrounding tissue. Before undergoing any procedure, understanding the potential risks is essential, as no procedure is risk free. The following risks are recognized, but there may also be risks not itemized here that have not been foreseen. The risks and complications associated with the ACT Injection procedure may include: Allergic or adverse reactions to bandages, tape, gauze, or agents used to clean the skin;Itching at the injection site; Numbness; Soft tissue swelling, bruising, or hematoma formation; Vasovagal reaction (i.e., fainting or dizziness) or nausea or vomiting; General disappointment; Temporary increased muscle spasm; Trauma to nerves including temporary or permanent nerve paralysis; Temporary injection and post-injection discomfort or pain; Infection (though rate of occurrence is extremely rare);Transmission of communicable, infectious or genetic diseases including bacterial, fungal or viral transmission; Immune rejection or allergic reaction to injection or DMSO (dimethyl sulfoxide) contained in injectable; Worsening of existing infections if injection is unknowingly performed on patient Recurrence of symptoms or unsatisfactory result; Damage to associated structures; Injury to adjacent tissues or nerve injury; Discoloration or injury to blood vessels; Irritation and swelling if a vein is injected; Tendon scarring resulting in pain on motion; Potential rupture of tendon if it is in path of injection and inadvertently injected; Minor bleeding post-injection; Tingling or unpleasant feeling in the area that was injected.

Alternatives

I have been advised of alternatives to the ACT Injection, which include: (1) Doing nothing, which typically leads to further joint degeneration, restricted mobility and pain; (2) Taking oral pain killers or anti-inflammatory agents, which do not correct the underlying problem and carry a risk of addiction, liver failure, gastro-intestinal bleeding, and death; (3) Joint replacement surgery, which carries risks similar to this procedure as well as blood clot, leg length discrepancy, joint dislocation, fracture, heart attack, infection including staphylococcus infections and MRSA, implant failure or prosthetic loosening, neurovascular damage, re-operation, stroke and death.

Patient Consents

By initialing in the spaces below, I acknowledge and agree that:

_______1. I understand that the ACT Injection procedure isNOT FDA approved

and have received the Notice of Non- FDA Approved Treatment stating the same, which is required to be provided to me under California law.

_______2. I have consulted with and been advised by my Provider(s) regarding the ACT Injection procedure; it has been

explained to me, including its benefits, side effects, and alternative treatments, and I understood this explanation.

_______3. I understand that no guarantees about the Results of this procedure have been made. I understand that Allograft Cellular Therapies are not warranted to cure any medical conditions nor provide immunity against re-occurrence of such conditions. I understand that I may not “feel” anything different after receiving the ACT Injection.

_______4. I have read the Risks listed above, understand them, and accept these risks in choosing to undergo the ACT Injection Procedure.

_______5. Alternative treatments, prescriptions and therapies – and their benefits, material risks and disadvantages – have been explained to me in terms I understand, along with the probable consequences of declining recommended or alternative therapies.

_______6. I understand that adverse reactions are possible and in the event of such a reaction it is my responsibility to contact my Provider and/or emergency medical personnel immediately.

_______7. While great measures to ensure the safety of the allograft product have been taken by the supplier, I understand that current technologies cannot preclude the transmission of certain diseases known or unknown, and that neither the supplier of the injectable nor the medical professional performing this procedure can make any claims concerning the biologic properties and safety of allograft tissues despite the tissue bank confirming it has collected, processed, screened, tested, stored, and distributed the product in compliance with all current FDA regulations concerning human cells, tissues, and cellular and tissue-based products.

_______8. I understand and accept that the procedure to which I am consenting is an intravenous or joint injection involving cells derived from the umbilical cord blood of a live healthy birth baby, and the details of this treatment including anticipated benefits, material risks and disadvantages have been explained to me in terms I understand.

_______9. I understand that Allograft Cellular Therapy is considered by insurance companies and others to be experimental, and thus it is not covered by insurance, and that no one can be fully aware of all possible side effects and complications of this protocol.

_______10. I have been advised of what to expect post-injection, including but not limited to estimated recovery time,anticipated activity level, and possibility of additional procedures, and I have also been informed that if I am to receive a local anesthesia and/or other pain management agents, or have an extremity joint injected which joint I am required to use for operation of a motor vehicle, that I will not operate a motor vehicle or dangerous machinery after same, and I will be accompanied to and from the office by a responsible adult, as necessary for the procedure, unless the local anesthesia or joint injection is unrelated to cognitive and motor functions and does not impact my ability to operate such vehicles or machinery.

_______11. I represent that I have informed the doctor of my known allergies, as well as all medications I am currently taking, including prescriptions, over-the-counter remedies, herbal therapies and supplements, aspirin, and other

recreational drug or alcohol use, and I have further been advised as to whether I should take any or all of these medications prior to the injection, the day of the injection, or in the days after the injection.

_______12. I represent that my Provider(s) has answered all of my questions regarding this treatment, and I understand the procedure to my complete satisfaction and have no unanswered questions. Accordingly, I authorize and direct my Provider(s) to perform, and/or assist as necessary, the ACT Injection or intravenous infusion. I further authorize the Provider(s) and its or their associated medical professionals to do any other procedure that in their judgment may be necessary or advisable should unforeseen circumstances arise during the procedure. My consent and authorization for this elective procedure is strictly voluntary. I have been informed of the possibility of complications as detailed above, from both known and unknown causes, and freely assume those risks. I understand that if I am not willing to accept all risks associated with this procedure then I should not have this treatment. I agree to adhere to all safety precautions and instructions before and after the treatment. I have been instructed in and understand post treatment instructions and have been given a written copy of them. I understand that medicine is not an exact science and acknowledge that no guarantee has been given or implied by anyone as to the results that may be obtained by this treatment. I also understand this procedure is "elective" and not covered by insurance and that payment is my responsibility.

Any expense which may be incurred for medical care I elect to receive outside of this office, such as, but not limited to dissatisfaction of my treatment outcome will be my sole financial responsibility. Payment in full for all treatments is required at the time of service and is nonrefundable. I understand that to receive homologous ACT Injection treatment and intravenous, I must comply with all stipulations outlined in this consent form; if I do not agree then I will not be able to proceed with treatment. I consent to the diagnosis, treatment plan, and ACT Injection and intravenous infusion, after having been advised of alternative treatments, the known material risks of the diagnosis and treatment to be used, and the consequences if these diagnostic and treatment procedures were to be withheld or refused. I certify that I have read this entire document, and understand this treatment agreement and that all blanks were filled in prior to executing my signature below.

My signature below represents that all of my questions have been answered in detail including the risks and possible benefits of this treatment.

By signing this form, I am requesting that my Rejuve Health Provider performs Exosome Therapy. My provider has informed me that this injection procedure, based on current medical evidence, is appropriate for my condition, though there can be no guarantee that the treatment will be effective or that my condition will improve. In addition, my provider has explained that there is a possibility that my condition could return. This procedure/treatment is not FDA approved.

Benefits & Alternatives Of Treatment

My Rejuve Health provider has fully explained to me the nature and the purpose of treatment. I have been explained how this treatment may benefit me and has also explained to me that there are other possible methods of treatment and explained what they are.

Risks

This treatment must be administered by a licensed medical professional and I have been informed of the potential risks and complications, from both known and unknown causes, that could reasonably be possible. Included in our discussion were the following risks: Some patients may experience local reactions at the site of treatment, including inflammation and or Infection. There is a small risk of hypersensitivity (allergic) reaction. Proliferation of existing cancer cells, worsening of myeloproliferative disease, primary pulmonary hypertension or “wet” macular degeneration however this has never been associated with this treatment before.

Withdrawal Of Consent

I understand that I am free to withdraw this consent and to discontinue treatment at any time.

No Guarantees

I acknowledge that no guarantees or assurances have been made to me concerning this treatment.

Financial Responsibility

I also acknowledge that I have been informed that my health insurance or other health care benefit plan will not cover this treatment. Nonetheless, I wish to have the treatment and understand that I am responsible for payment of this treatment myself. I understand that Rejuve Health will not submit a claim to my insurance.

Understanding of this Form

I acknowledge that I have read this document in its entirety and that I fully understand it and that all blank spaces have been either completed or crossed off prior to my signing and all of my questions have been answered.

Female Testosterone And/Or Estradiol Pellet Insertion Consent Form

Bio-identical hormone pellets are hormones, biologically identical to the hormones you make in your own body prior to menopause. Estrogen and testosterone were made in your ovaries and adrenal gland prior to menopause. Bio-identical hormones have the same effects on your body as your own estrogen and testosterone did when you were younger, without the monthly fluctuations (ups and downs) of menstrual cycles. Bio-identical hormone pellets are plant derived and are FDA monitored, but not FDA approved for female hormonal replacement. The pellet method of hormone replacement has been used in Europe and Canada for many years and by select OB/GYNs in the United States. You will have similar risks as you had prior to menopause, from the effects of estrogen and androgens, given as pellets. Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone is category X (will cause birth defects) and cannot be given to pregnant women.

CONCEPTION WHILE ON HORMONE REPLACEMENT THERAPY IS NOT RECOMMENDED

Consent For Treatment

I consent to the insertion of testosterone and/or estradiol pellets in my hip. I have been informed that I may experience any of the complications to this procedure as described below. These side effects are similar to those related to traditional testosterone and/or estrogen replacement. Surgical risks are the same as for any minor medical procedure and are included in the list of overall risks below:

Bleeding, bruising, swelling, infection and pain; reaction to local anesthetic and/or

preservatives; extrusion of pellets; hyper sexuality (overactive Libido); lack of effect (from lack of absorption); breast tenderness and swelling especially in the first three weeks (estrogen pellets only); increase in hair growth on the face, similar to pre-menopausal patterns; water retention (estrogen only); increased growth of estrogen dependent tumors (endometrial cancer, breast cancer); birth defects in babies exposed to testosterone during their gestation; growth of liver tumors, if already present; change in voice (which is reversible); clitoral enlargement (which is reversible).

The estradiol dosage that I may receive can aggravate fibroids or polyps, if they exist, and can cause bleeding. Testosterone therapy may increase one’s hemoglobin and hematocrit, or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin & Hematocrit) should be done at least annually. This condition can be reversed simply by donating blood periodically. I understand that I may also require progesterone, and I will be compliant with taking this medication.

Benefits Of Testosterone Pellets Include

Increased libido, energy, and sense of well-being; increased muscle mass and strength and stamina; decreased frequency and severity of migraine headaches; decrease in mood swings, anxiety and irritability; decreased weight; decrease in risk or severity of diabetes; decreased risk of heart disease; decreased risk of Alzheimer’s and dementia. Alternatives include not doing the pellets, since this is an elective procedure. I have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone and or estrogen therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications, including one or more of those listed above. I accept these risks and benefits, and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future pellet insertions.

Breast Cancer Waiver For Estradiol Pellet Therapy

I voluntarily choose to undergo implantation of subcutaneous bio-identical estradiol

pellet therapy. My Treating Provider has informed me it is possible that taking Estradiol could stimulate existing breast cancer (including one that has not yet been detected). Accordingly, I am aware that breast cancer or other cancer could develop while on pellet therapy.

I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was informed of by my Treating Provider.

I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or cancer issues) that may be sustained by me in connection with my decision to undergo estradiol pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer.

I hereby release and agree to hold harmless Megan Retterath NP, all other treating providers at Rejuve-Health, physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of estradiol pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

Mammogram Waiver For Testosterone And/Or Estradiol Pellet Therapy

I voluntarily choose to undergo implantation of subcutaneous bio-identical testosterone and/or estradiol pellet therapy, even though I may not current on my yearly mammogram. I understand that such therapy is controversial and that many doctors believe that estradiol replacement in my case is contraindicated. My Treating Provider has informed me it is possible that taking estradiol could possibly cause cancer, or stimulate existing breast cancer (including one that has not yet been detected). Accordingly, I am aware that breast cancer or other cancer could develop while on pellet therapy. For today’s appointment I DO NOT have a mammogram for any of the following reasons: My decision not to have one, Unable to provide the report at this time, My doctor’s decision not to have one. Please provide a note from your treating physician with their rationale as to why they don’t want you to have a mammogram. I am aware that a current report must be sent by mail or faxed to our office prior to my next HRT appointment. The Treating Provider has discussed the importance and necessity of a mammogram since I receive testosterone and/or estradiol. I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was informed of by my Treating Provider. I understand that mammograms are a superior method for detection of early breast cancer. I understand that my refusal to submit to a mammogram test may result in cancer remaining undetected within my body. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or breast, uterine or cancer issues) that may be sustained by me in connection with my decision to not have a mammogram and undergo testosterone and/or estradiol pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Megan Retterath NP, all other treating providers at Rejuve-Health physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone and/or estradiol pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

Ovarian Cancer Waiver For Testosterone &/Or Estradiol Pellet Therapy

I voluntarily choose to undergo implantation of subcutaneous bio-identical estradiol pellet therapy, even though I have a history of ovarian cancer. I understand that such therapy is controversial and that many doctors believe that estradiol replacement in my case is contraindicated. My Treating Provider has informed me it is possible that taking Testosterone and/or Estradiol could possibly cause cancer, or stimulate existing ovarian cancer (including one that has not yet been detected).

Accordingly, I am aware that ovarian cancer or other cancer could develop while on pellet therapy. I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was informed of by my Treating Provider.

I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or cancer issues) that may be sustained by me in connection with my decision to undergo testosterone and/or estradiol pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Megan Retterath NP, all other treating providers at Rejuve Health physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone and/or estradiol pellet therapy. I acknowledge and agree that I have been given

adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

Pap and Transvaginal Ultrasound Waiver For Testosterone &/Or Estradiol Pellet Therapy

I voluntarily choose to undergo implantation of subcutaneous bio- identical testosterone and/or estradiol pellet therapy.

For today’s appointment I DO NOT have recent documentation of a normal PAP Smear for one of the following reasons: My decision not to have one; Unable to provide the report at this time; My doctor’s decision not to have one. Please provide a note from your treating physician with their rationale as to why they don’t want you to have a PAP Smear.

For today’s appointment I DO NOT have a Transvaginal Ultrasound for one of the following reasons: My decision not to have one; Unable to provide the report at this time; My doctor’s decision not to have one. Please provide a note from your treating physician with their rationale as to why they don’t want you to have a Transvaginal Ultrasound.

I am aware that a current report must be sent by mail or faxed to our office prior to my next HRT appointment. The Treating Provider has discussed the importance and necessity of a Pap smear and/or Transvaginal Ultrasound since I receive testosterone and/or estradiol. I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was informed of by my Treating Provider.

I understand that PAP smear and/or Transvaginal Ultrasounds are the best single method for detection of early ovarian, endometrial and/or cervical cancer. I understand that my refusal to submit to a Pap smear and/or Transvaginal Ultrasound may result in cancer remaining undetected within my body. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or cervical, endometrial and/or ovarian cancer issues) that may be sustained by me in connection with my decision to not have a PAP Smear and/or Transvaginal Ultrasound and undergo testosterone and/or estradiol pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold

harmless Megan Retterath NP, all other treating providers at Rejuve-Health physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone and/or estradiol pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

Bio-Identical Hormone Replacement Therapy (BHRT)

I hereby authorize and direct Rejuve Health, with qualified associates or assistants of choice, to perform Bio-Identical Hormone Replacement therapy (BHRT) injections on myself.

I authorize the above people to do any other procedure that his judgment may dictate to be necessary or advisable should unforeseen circumstances arise during the procedure.

Risk Benefits And Alternatives

The details of this procedure have been explained to me in terms and language that I could understand.

I understand that the procedure may not be effective, and Rejuve-Health nor any of the above office staff are responsible for this. There are no refunds or complimentary repeat procedures performed.

The risks, if any, of not having the operation or procedure have been discussed.

I am advised that although good results are expected, complications cannot be anticipated and that therefore there can be no guarantee, either expressed or implied, as the result of the procedure. I also understand that additional procedures may be necessary to achieve the desired outcome, and I will be financially responsible for these procedures.

I authorize and direct the above persons with his associates or assistants to provide such additional services they may deem reasonable and necessary including, but not limited to, the administration of any anesthetic agent and the services of x-ray and laboratory.

I hereby grant permission for the use of any record, illustration, photograph or other imaging record created in my case for use in examination, education, and record keeping. (I have read the above risks, benefits, and alternatives and understand completely)

Release Info

Patient acknowledges and agrees that this release applies to all claims that Patient may have against Physician or Nurse arising out of the above-described medical services and treatment for injuries, damages, or losses to Patient's person, whether those injuries, damages, or losses are known or unknown, foreseen or

unforeseen, or patent or latent.

Patient certifies that he/she has read Section 1542 of the Civil Code, set out below. A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.

Patient hereby waives application of Section 1542 of the Civil Code.

Patient understands and acknowledges that the significance and consequence of this waiver of Section 1542 of the Civil Code is that even if Patient should eventually suffer additional damages arising out of the above-described medical services and treatment he/she will not be permitted to make any claim for those damages. Furthermore, Patient acknowledges that he/she intends these consequences even as to claims for injury and/or damages that may exist as of the date of this release but which Patient does not know exist, and which, if known, would materially affect Patient's decision to execute this release, regardless of whether

Patient's lack of knowledge is the result of ignorance, oversight, error, negligence, or any other cause.

Patient warrants and represents that in executing this release, he/she has been given an opportunity to obtain legal advice from an attorney of his/her choice regarding the terms of this release and its consequences and that Patient fully understands the terms of this release.

Patient acknowledges and represents that in executing this release, he/she has not relied on any inducements, promises, or representations made by Physician or any party representing or serving Physician.

Patient acknowledges and warrants that his/her execution of this release is free and voluntary.

I ACKNOWLEDGE THAT I AM TREATED UNDER MD SUPERVISION.

Request To Restrict Disclosure To Health Plan

{Authorized by Section 13405(a) of the HITECH Act}

I request that Rejuve-Health (the “Practice”) not disclose my protected health Information (PHI) to my health plan or other third party insurance carrier. Pursuant to Section 13405(a) of the HITECH Act, I understand I have the right to request restrictions on whether the Practice discloses my protected health information (PHI) with my health plan and the Practice is required to agree to my request unless the information is required to be disclosed to my health plan to comply with the law. The records of the restricted services/items listed below (“Restricted Services/Items”) will not be released or billed to my health plan or other third party insurance carrier for the purposes of payment or health care operations. I understand I am financially responsible for these Restricted Services/Items and will pay out-of-pocket, in full, at the time of service in order for the Practice to accept this restriction request. I have read all of the above risks, benefits, and alternatives, waivers and releases and understand completely. I request to have hormone pellet therapy performed.

Insurance Disclaimer

Preventative medicine and bio-identical hormone replacement is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as Medical Doctors and RN’s or NP’s, insurance does not recognize it as necessary medicine BUT is considered like plastic surgery (esthetic medicine) and therefore is not covered by health insurance in most cases.

Rejuve-Health is not associated with any insurance companies, which means they are not obligated to pay for our services (blood work, consultations, insertions or pellets). We require payment at time of service and, if you choose, we will provide a form to send to your insurance company and a receipt showing that you paid out of pocket. WE WILL NOT, however, communicate in any way with insurance companies.

The form and receipt are your responsibility and serve as evidence of your treatment. We will not call, write, pre-certify, or make any contact with your insurance company. Any follow up letters from your insurance to us will be thrown away. If we receive a check from your insurance company, we will not cash it, but instead return it to the sender. Likewise, we will not mail it to you. We will not respond to any letters or calls from your insurance company. For patients who have access to Health Savings Account, you may pay for your treatment with that credit or debit card. This is the best idea for those patients who have an HSA as an option in their medical coverage.

What Might Occur After A Pellet Insertion

A significant hormonal transition will occur in the first four weeks after the insertion of your hormone pellets. Therefore, certain changes might develop that can be bothersome.

Fluid Retention

Testosterone stimulates the muscle to grow and retain water, which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions.

Swelling Of The Hands And Feet

This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, taking cider vinegar capsules daily, (found at most health and food stores) or by taking a mild diuretic, which the office can prescribe.

Uterine Spotting/Bleeding

This may occur in the first few months after an insertion, especially if you have been prescribed progesterone and are not taking properly: i.e. missing doses, or not taking a high enough dose. Please notify the office if this occurs. Bleeding is not necessarily an indication of a significant uterine problem. More than likely, the uterus may be releasing tissue that needs to be eliminated. This tissue may have already been present in your uterus prior to getting pellets and is being released in response to the increase in hormones.

Mood Swings/Irritability

These may occur if you were quite deficient in hormones. They will disappear when enough hormones are in your system. 5HTP can be helpful for this temporary symptom and can be purchased at many health food stores.

Facial Breakout

Some pimples may arise if the body is very deficient in testosterone. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.

Hair Loss

Is rare and usually occurs in patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases.

Hair Growth

Testosterone may stimulate some growth of hair on your chin, chest, nipples and/or lower abdomen. This tends to be hereditary. You may also have to shave your legs and arms more often. Dosage adjustment generally reduces or eliminates the problem. Laser Hair removal is also available.

Post-Insertion Instructions For Women

Your insertion site has been covered with two layers of bandages. Remove the outer pressure bandage any time after 24 hours. It must be removed as soon as it gets wet. The inner layer is either waterproof foam tape or steri-strips. They should be removed in 3 days.

We recommend putting an ice pack on the insertion area a couple of times for about 20 minutes each time over the next 4 to 5 hours.

Do not take tub baths or get into a hot tub or swimming pool for 5 days. You may shower but do not scrub the site until the incision is well healed (about 7 days).

No major exercises for the incision area for the next 5 days, this includes running, elliptical, squats, lunges, etc.

The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days.

The insertion site may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief, 50 mg. orally every 6 hours. Caution this can cause drowsiness!

You may experience bruising, swelling, and/or redness of the insertion site which may last from a few days up to 2 to 3 weeks.

You may notice some pinkish or bloody discoloration of the outer bandage. This is normal.

If you experience bleeding from the incision, apply firm pressure for 5 minutes.

Please call if you have any bleeding not relieved with pressure (not oozing), as this is NOT normal.

Please call if you have any Drainage coming out of the insertion site, as this is NOT normal.

Reminders

Remember to go for your post-insertion blood work 6 weeks after the insertion. Most women will need re-insertions of their pellets 3-4 months after their initial Insertion.

Female Post-Pellet Treatment Plan

The following medications or supplements are recommended in addition to your pellet therapy. Please refer to the supplement brochure to help you understand why these are beneficial. Unless specified, these can be taken any time of day without regards to meals.

Supplements & Prescriptions

_______ DIM Supplement Daily

_______ Minocycline/Doxycycline

_______ Progesterone 100 mg every night (will make you sleepy) Please do not skip doses of this medication as it can result in vaginal bleeding or an increased risk for endometrial cancer. This dose may also range throughout treatment.

_______ Spironolactone 100 mg daily

Please call or email for any questions about these recommendations.

Consent For Testosterone Pellet Insertion

Bio-identical testosterone pellets are hormone, biologically identical to the testosterone that is made in your own body. Testosterone was made in your testicles prior to “andropause.” Bio-identical hormones have the same effects on your body as your own testosterone did when you were younger. Bio-identical hormone pellets are plant derived and bio-identical hormone replacement using pellets has been used in Europe, the U.S. and Canada since the 1930’s. Your risks are similar to those of any testosterone replacement but may be lower risk than alternative forms. During andropause, the risk of not receiving adequate hormone therapy can outweigh the risks of replacing testosterone. Risks of not receiving testosterone therapy after andropause include but are not limited to: Arteriosclerosis, elevation of cholesterol, obesity, loss of strength and stamina, generalized aging, osteoporosis, mood disorders, depression, arthritis, loss of libido, erectile dysfunction, loss of skin tone, diabetes, increased overall inflammatory processes, dementia and Alzheimer’s disease, and many other symptoms of aging.

Consent For Treatment

I consent to the insertion of testosterone pellets in my hip. I have been informed that I may experience any of the complications to this procedure as described below. Surgical risks are the same as for any minor medical procedure. Side effects may include: Bleeding, bruising, swelling, infection, pain, reaction to local anesthetic and/or preservatives, lack of effect (typically from lack of absorption), thinning hair, male pattern baldness, increased growth of prostate and prostate tumors, extrusion of pellets, hyper sexuality (overactive libido), ten to fifteen percent shrinkage in testicle size and significant reduction in sperm production. There is some risk, even with natural testosterone therapy, of enhancing an existing current prostate cancer to grow more rapidly. For this reason, a prostate specific antigen blood test is to be done before starting testosterone pellet therapy and will be conducted each year thereafter. If there is any question about possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before improving. Testosterone therapy may increase one’s hemoglobin and hematocrit, or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin and Hematocrit.) should be done at least annually. This condition can be reversed simply by donating blood periodically.

Benefits Of Testosterone Pellets Include

Increased libido, energy, and sense of well-being; increased muscle mass and strength and stamina; decreased frequency and severity of migraine headaches; decrease in mood swings, anxiety and irritability (secondary to hormonal decline); decreased weight (increase in lean body mass); decrease in risk or severity of diabetes; decreased risk of Alzheimer’s and dementia; and decreased risk of heart disease in men less than 75 years old with no pre-existing history of heart disease. 3 On January 31, 2014, the FDA issued a Drug Safety Communication indicating that the FDA is investigating risk of heart attack and death in some men taking FDA approved testosterone products. The risks were found in men over the age of 65 years old with pre-existing heart disease and men over the age of 75 years old with or without pre-existing heart disease.

These studies were performed with testosterone patches, testosterone creams and synthetic testosterone injections and did not include subcutaneous hormone pellet therapy. I agree to immediately report to my practitioner's office any adverse reactions or problems that may be related to my therapy. Potential complications have been explained to me and I agree that I have received information regarding those risks, potential complications and benefits, and the nature of bio-identical and other treatments and have had all my questions answered. Furthermore, I have not been promised or guaranteed any specific benefits from the administration of bio-identical therapy. I certify this form has been fully explained to me, and I have read it or have had it read to me and I understand its contents. I accept these risks and benefits and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future insertions. I understand that payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not reimburse me, depending on my coverage. I acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal.

Prostate Cancer Waiver For Testosterone Pellet Therapy

I voluntarily choose to undergo implantation of subcutaneous bio-identical testosterone pellet therapy with, Rejuve-Health Medical provider even though I may have a history of prostate cancer. I understand that such therapy is controversial and that many doctors believe that testosterone replacement in my case is contraindicated. My Treating Provider has informed me it is possible that taking testosterone could possibly cause cancer, or stimulate existing prostate cancer (including one that has not yet been detected). Accordingly, I am aware that prostate cancer or other cancer could develop while on pellet therapy. I have assessed this risk on a personal basis, and my perceived value of the hormone therapy outweighs the risk in my mind. I am, therefore, choosing to undergo the pellet therapy despite the potential risk that I was informed of by my Treating Provider. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or prostate issues) that may be sustained by me in connection with my decision to undergo testosterone pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Megan Retterath NP, and all other treating providers at Rejuve-Health physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

Prostate Exam Waiver For Testosterone Pellet Therapy

I voluntarily choose to undergo implantation of subcutaneous bio-identical testosterone pellet therapy with Rejuve-Health Medical Provider for today’s appointment, I have not provided you with a prostate exam report, due to one of the following reason: either my own personal decision not to have a prostate exam or I am unable to provide it at this time. I have been offered a prostate exam today. I am aware that a current report must be sent by mail or faxed to our office prior to my next HRT appointment. The Treating Provider has discussed the importance and necessity of prostate exam since I received testosterone. A prostate exam is the best single method for detection of early prostate cancer. I understand that my refusal to submit to a prostate exam may result in cancer remaining undetected within my body. Hormone therapy may increase the risk of increase of such undetected cancer. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or prostate issues) that may be sustained by me in connection with my decision to undergo testosterone pellet therapy including, without limitation, any cancer that should develop in the future, whether it be deemed a stimulation of a current cancer or a new cancer. I hereby release and agree to hold harmless Megan Retterath NP, all other treating providers at Rejuve Health physicians, nurses, officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of testosterone pellet therapy. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

Bio-identical Hormone Replacement Therapy (BHRT) Consent Form

I here by authorize and direct Rejuve Health, with qualified associates or assistants of choice, to perform Bio-Identical hormone replacement therapy (BHRT) on myself.

I authorize the above people to do any other procedure that their judgment may dictate to be necessary or advisable should unforeseen circumstances arise during the procedure.

Risks Benefits And Alternatives

The details of this procedure have been explained to me in terms and language that I could understand. I understand that the procedure may not be effective, and Rejuve-Health nor any of the above office staff are responsible for this. There are no refunds or complimentary repeat procedures performed. The risks, if any, of not having the operation or procedure have been discussed. I am advised that although good results are expected, complications cannot be anticipated and that therefore there can be no guarantee, either expressed or implied, as the result of the procedure. I also understand that additional procedures may be necessary to achieve the desired outcome, and I will be financially responsible for these procedures. I authorize and direct the above persons with his associates or assistants to provide such additional services they may deem reasonable and necessary including, but not limited to, the administration of any anesthetic agent and the services of x-ray and laboratory. I hereby grant permission for the use of any record, illustration, photograph or other imaging record created in my case for use in examination, education, and record keeping.

Release Info

Patient acknowledges and agrees that this release applies to all claims that Patient may have against Physician or Nurse arising out of the above-described medical services and treatment for injuries, damages, or losses to Patient's person, whether those injuries, damages, or losses are known or unknown, foreseen or

unforeseen, or patent or latent.

Patient certifies that he/she has read Section 1542 of the Civil Code, set out below. A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.

Patient hereby waives application of Section 1542 of the Civil Code.

Patient understands and acknowledges that the significance and consequence of this waiver of Section 1542 of the Civil Code is that even if Patient should eventually suffer additional damages arising out of the above-described medical services and treatment he/she will not be permitted to make any claim for those damages. Furthermore, Patient acknowledges that he/she intends these consequences even as to claims for injury and/or damages that may exist as of the date of this release but which Patient does not know exist, and which, if known, would materially affect Patient's decision to execute this release, regardless of whether

Patient's lack of knowledge is the result of ignorance, oversight, error, negligence, or any other cause.

Patient warrants and represents that in executing this release, he/she has been given an opportunity to obtain legal advice from an attorney of his/her choice regarding the terms of this release and its consequences and that Patient fully understands the terms of this release.

Patient acknowledges and represents that in executing this release, he/she has not relied on any inducements, promises, or representations made by Physician or any party representing or serving Physician.

Patient acknowledges and warrants that his/her execution of this release is free and voluntary.

I ACKNOWLEDGE THAT I AM TREATED UNDER MD SUPERVISION.

Request To Restrict Disclosure To Health Plan

{Authorized by Section 13405(a) of the HITECH Act}

I request that Rejuve-Health (the “Practice”) not disclose my protected health Information (PHI) to my health plan or other third party insurance carrier. Pursuant to Section 13405(a) of the HITECH Act, I understand I have the right to request restrictions on whether the Practice discloses my protected health information (PHI) with my health plan and the Practice is required to agree to my request unless the information is required to be disclosed to my health plan to comply with the law. The records of the restricted services/items listed below (“Restricted Services/Items”) will not be released or billed to my health plan or other third party insurance carrier for the purposes of payment or health care operations. I understand I am financially responsible for these Restricted Services/Items and will pay out-of-pocket, in full, at the time of service in order for the Practice to accept this restriction request. I have read all of the above risks, benefits, and alternatives, waivers and releases and understand completely. I request to have hormone pellet therapy performed.

Insurance Disclaimer

Preventative medicine and bio-identical hormone replacement is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as Medical Doctors and RN’s or NP’s, insurance does not recognize it as necessary medicine BUT is considered like plastic surgery (esthetic medicine) and therefore is not covered by health insurance in most cases.

Rejuve-Health is not associated with any insurance companies, which means they are not obligated to pay for our services (blood work, consultations, insertions or pellets). We require payment at time of service and, if you choose, we will provide a form to send to your insurance company and a receipt showing that you paid out of pocket. WE WILL NOT, however, communicate in any way with insurance companies.

The form and receipt are your responsibility and serve as evidence of your treatment. We will not call, write, pre-certify, or make any contact with your insurance company. Any follow up letters from your insurance to us will be thrown away. If we receive a check from your insurance company, we will not cash it, but instead return it to the sender. Likewise, we will not mail it to you. We will not respond to any letters or calls from your insurance company. For patients who have access to Health Savings Account, you may pay for your treatment with that credit or debit card. This is the best idea for those patients who have an HSA as an option in their medical coverage.

What Might Occur After A Pellet Insertion

A significant hormonal transition will occur in the first four weeks after the insertion of your hormone pellets. Therefore, certain changes might develop that can be

bothersome.

Fluid Retention

Testosterone stimulates the muscle to grow and retain water which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions.

Swelling Of The Hands & Feet

This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, taking cider vinegar capsules daily, (found at most health and food stores) or by taking a mild diuretic, which the office can prescribe.

Mood Swings/Irritability

These may occur if you were quite deficient in hormones. They will disappear when enough hormones are in your system.

Facial Breakout

Some pimples may arise if the body is very deficient in testosterone. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.

Hair-Loss

Is rare and usually occurs in patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases.

Post-Insertion Instructions For Men

Your insertion site has been covered with two layers of bandages. The inner layer is a steri-strip and the outer layer is a waterproof dressing.

We recommend putting an ice pack on the insertion area a couple of times for about 20 minutes each time over the next 4 to 5 days.

Be sure to place something between the ice pack and your bandages/skin.

Do not place ice packs directly on bare skin.

No tub baths, hot tubs, or swimming pools for 7 days You may shower, but do not scrub the site until the incision is well healed (about 7 days).

No major exercises for the incision area for 7 days. This includes running,elliptical, squats, lunges, etc. You can do moderate upper body work and walking.

The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days. Swelling to the area is expected and encourage you to continue icing following the procedure.

The insertion site may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief, 50 mg. orally every 6 hours. Caution this can cause drowsiness!

You may experience bruising, swelling, and/or redness of the insertion site which may last from a few days up to 2 to 3 weeks. You may notice some pinkish or bloody discoloration of the outer bandage. This is normal. If you experience bleeding from the incision, apply firm pressure for 5 minutes. Please call if you have any bleeding (not oozing) not relieved with pressure, as this

is NOT normal. Please call if you have any pus coming out of the insertion site, as this is NOT

normal.

Reminders:

Remember to go for your post-insertion blood work4 weeks after the insertion. Most men will need re-insertions of their pellets 5-6 months after their initial insertion.

Male Post-Pellet Treatment Plan

The following medications or supplements are recommended in addition to your pellet Therapy. Please refer to the supplement brochure to help you understand why these are beneficial. Unless otherwise specified, these can be taken any time of day without regards to meals.

Supplements/Prescriptions

The following may be in addition to your current hormone treatment plan:

_______ DIM Supplement Daily

_______ Minocycline/Doxycycline

_______ Anastrazole (Arimidex)

_______ Wean off your antidepressant (see wean protocol)

Please call or email for any questions about these recommendations.

nformed Consent For Purchase & Treatment With Peptides

I am executing this consent to confirm my decision to purchase peptides with Megan Retterath, NP of Rejuve Wellness, LLC and to verify my understanding of the risks and alternatives to treatment with peptide therapy.

The goals and possible benefits of this therapy are to try and prevent, reduce or control the dysfunction associated with the aging process, through hormonal balancing, control of oxidative stress, and stimulating the body's own innate repair systems. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, and unnecessary by the Food and Drug Administration (FDA).

Risks

The following are examples of some of the possible minor risks/adverse reactions reported for the peptide therapy that may be prescribed for me. At prescribed doses, there are not expected to be any significant risks/adverse reactions as long as full medical disclosure is achieved from the patient during the total time of therapy.

Some adverse reactions may include but are not limited to injection site redness, flushing, transient high blood sugar, development of antibodies peptides, and water retention. These side effects are dose related and usually eliminated by adjusting the dosage. This drug should not be used in patients with known cancer or are pregnant.

By signing this form, I understand the possible risks associated with this treatment. I understand that Rejuve Wellness, LLC will monitor my treatment in an effort to manage any side effects, but cannot guarantee that I will not experience any side effects or adverse reactions. I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy.

I certify that I have read the foregoing Informed Consent, discussed the issues noted above, had opportunities to ask questions, and agree and accept all of the terms above.

Consent for Vitamin IV Therapy

I, _______________________________________, hereby give my voluntary consent to receive intravenous (IV) Vitamin IV Therapy® per the outlined protocol. The procedure is to be administered by the licensed nursing staff of under the direct orders of Megan Retterath, NP.

I Fully Understand & Am Fully Aware That

_____ The desired effect, improvement, or relief of any condition for which Vitamin IV therapy is to be applied may or may not be attained. Moreover, VitaminIV® does not preclude the need for other forms of therapy and I assume full responsibility for the treatment of my condition by other physicians practicing standard medicine, as may be deemed necessary for my well-being.

_____ There may be complications resulting from this procedure which could include but are not limited to infection, nausea, vomiting, diarrhea, pain and discomfort, weakness, fainting, micro-hemorrhages, ecchymosis, embolism, allergic reactions, shock, IV fluid infiltration, swelling, needle breakage and its retention, death, and even aggravation of current symptoms. Most patients report mild symptoms during the administration of FastVitaminIV® that are transient.

_____ No assurances or guarantees have been made, nor can any be made concerning the results that may be obtained, but the physicians and nurses who will provide the treatment which I will undergo will perform their services, and take such precautions that are consistent with the standards of care that prevail for the same type of treatment provided to patients with conditions similar to mine.

By signing this consent form I have not waived any of my legal rights or released this institution from liability for negligence. I also understand that I may revoke my consent at any time and withdraw from any further treatment without prejudice.

My Signature Below Confirms That

1. I understand the information provided on this form and agree to the foregoing.

2. The procedure(s) set forth above has been adequately explained to me by my nurse/physician.

3. I have received all the information and explanation I desire concerning the procedure.

4. I certify that I am not pregnant.

5. I certify that I am not intoxicated on alcohol or any illicit drugs.

6. I authorize and consent to the performance of the procedure(s).

Patient Blood Work Review Acknowledgement & Consent

I request and consent to an evaluation by Rejuve Health and its staff (collectively, “Practice”) of a certain laboratory test(s) run on my blood (“Bloodwork”). I wish to rely on Practice to exercise its professional judgment only in reviewing the results of my Bloodwork and making suggestions regarding healthcare services resulting from such results. I acknowledge, agree, and certify that:

1. Practice is not my primary care provider.

2. Practice’s only function as it relates to me is the review of my Bloodwork and related recommendations.

3. Practice’s recommendations are not a treatment order and I will not treat them as such.

4. It is solely my duty and responsibility to follow up with my primary care provider regarding my

results and recommendations.

5. As part of my follow up, I will share the results of my Bloodwork and Practice’s recommendations with my primary care provider.

6. My primary care provider must review Practice’s results and recommendations, approve or modify the same, and develop a treatment plan for me.

7. I will not act on the Bloodwork results or Practice recommendations without the involvement of my primary care provider. I understand that Practice is not treating me and any questions I may have regarding my treatment, potential treatments, alternatives to such treatments, potential side-effects, and complications should be directed to my primary care provider. I further understand that if I desire for Practice to treat me, I must engage Practice separately and apparat from this Acknowledgement and Consent and complete the appropriate patient intake paperwork and assessment.

I also understand that this Acknowledgement and Consent does not establish me as a patient of Practice and will not result in treatment by Practice. I understand that the practice of medicine and surgery is not an exact science. I further understand and accept that fees are paid for performance of medical services only, and not a guaranteed result. I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained.