Telemedicine Informed Consent This document serves as informed consent for a telemedicine patient encounter and outlines the specific rights and responsibilities associated with this form of healthcare. Telemedicine is a type of care delivery that uses modern technologies, such as telecommunications technology, to provide remote healthcare services to patients who may otherwise lack access to conventional in-person care. The purpose of this consent form is to ensure that all participants are aware of their rights and responsibilities associated with the telemedicine encounter. Please read the following information carefully before signing below. By signing this consent form, you acknowledge that you have fully reviewed and understand the risks, benefits, and alternatives associated with telemedicine encounters. You further acknowledge that you understand the potential implications of participating in a telemedicine encounter, including but not limited to:

• Your provider will be using audio/video technology to assess your medical condition during your appointment;
• The quality of the audio/video communication may be compromised due to technical limitations or other factors beyond our control;
• There is no guarantee that any confidential medical information shared during the telemedicine encounter will remain secure;
• Neither party has an obligation to continue participation in a telemedicine encounter if either party deems it necessary for safety reasons;
• You have the right to discontinue participation in the telemedicine encounter at any time without consequences or penalty.

In addition, by agreeing to participate in a telemedicine encounter, you agree not to hold your provider liable for any damages resulting from technical malfunctions or other issues beyond their control. Furthermore, you acknowledge that it is solely your responsibility to take reasonable steps towards protecting yourself from data breaches or unauthorized access when engaging in a telemedicine session (e.g., accessing your account via password-protected resources). We thank you for taking part in this important research into new ways of delivering healthcare services more efficiently and effectively. By signing below, I confirm that I have read and understand all of the above statements regarding my rights and responsibilities pertaining to participating in a telemedicine patient encounter. I also confirm my agreement with these statements as well as my willingness to participate in this research endeavor wholeheartedly. Disclaimer and Release of Medical-Legal Liability for obtaining a “Good Faith Exam” via a digital health apparatus. This tele-medical evaluation is not intended to be construed as a general or complete medical examination. It is for the purposes of establishing a relationship with the medical director who is a licensed physician providing supervision of the med spa you are attending. Kindly understand that this consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. Kindly understand that there are certain limitations to the use of the app to meet your doctor. If at any time you would like to speak to the doctor on the phone, through videoconferencing, at an in person appointment, or for a follow up visit, please let your staff member know and we will arrange for this for you. You always have the right to see the physician and the physician is always on standby to take care of your needs! I understand that others may also be present during the consultation other than my health care provider and the Consulting health care provider in order to operate the application. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time. In an emergent consultation, I understand that the responsibility of the telemedicine provider is to notify local emergency response systems and that their responsibility will conclude upon the termination of the video conference connection. I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby consent to participate in a telemedicine visit under the terms described herein. I, the undersigned patient, hereby declare that all of the information I am providing today to be true and correct.

HIPAA Compliance Document We are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective May 31st, 2017 and applies to all protected health information as defined by federal regulation. Uses and Disclosures: We use your health information to document and plan treatment, progress, planning, etc. We use your health information for payment. For instance, we may need to send health information including procedures done and diagnoses to your insurance company. We use your health information for regular health operations. For example, our compliance officer regularly chooses medical records for audits. This practice ensures that we are constantly working towards improved quality and effectiveness. There are services provided in our organization through contacts with business associates. Examples include outside labs, x-ray, and transcription services. We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, your location, and general condition. The following are examples of other purposes for which your provider of services is permitted or required to disclose confidential information without the individual’s written authorization: Uses and disclosures for public health activities; Reporting victims of abuse, neglect, or domestic violence; Disclosures for judicial and administrative proceedings; Disclosures for law enforcement purposes; Uses and disclosures for cadaveric organ, eye or tissue donation purposes; Disclosures to avert a serious threat to health or safety; and Uses and disclosures for specialized government functions. Separate Statements for Certain Uses or Disclosures The provider of services may contact patients with appointment reminders, requests for the patient to contact the office staff for appointments, notices, and letters concerning medical findings. The provider of services may also contact the patient about treatment alternatives or other health related benefits and services that may be of interest to the individual. Individual Rights Although your health record is the physical property of the provider of services, the information belongs to you. You have the right to: Request restrictions on certain uses and disclosures of your information; Revoke your authorization to use or disclose health information except to the extent that action has already been taken. Receive confidential communications; Obtain a copy or inspect your health information; Amend protected health information; Receive an accounting of disclosures of protected health information. The provider of services has 30 days with which to comply with a patient request to review or copy their health information. The provider of services is allowed an additional 30 days if the record is off site. The provider of services may charge a fee for copying the health record. The physicians have the right to review the record and remove any information that they deem to be harmful to either the patient or to another individual; The patient will be supervised by the provider of services or ancillary staff during any review of the record. Supervision is allowed and required to prevent the removal or altering of the medical record. The provider of services will charge staff time for this service. HIPAA Privacy Notice The provider of services is required by law to maintain the privacy of confidential information and provide individuals with notice of its legal duties and privacy practices with respect to such information; The provider of services is required to abide by the terms of this Notice; and the provider of services reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all confidential information that it maintains. Revisions to this Notice will be posted in the patient waiting area. Complaints Individuals may complain to the Office Manager in writing to address below. You may also contact the Secretary of the U.S. Department of Health and Human Services at 200 Independence Ave., S.W., Rm. 509F, HHH Building, Washington D.C. 20201. Further Information-Please contact the provider of services administrator at their listed number for further information. I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Arbitration Agreement Article 1: Agreement to Arbitrate It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must be Arbitrated It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present, or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with, or serving as a back-up for the health care provider, including those working at the health care providers’ clinic or office or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care providers associates, association, corporation, partnership, employees, agents, and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. Article 3: Procedures and Applicable Law A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party's own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement. Article 4: General Provision All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. Article 5: Revocation This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties. Article 6: Retroactive Effect If a patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), the patient should initially also sign below. Effective as the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have made my request known to receive a copy or not. NOTE: By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration, and you are giving up your right to a jury or court trial. See Article 1 of this contract.

Patient Financial Responsibility Agreement Your photo-identification will be photocopied and stored in your medical record for your protection and security. This account is self-pay, and payment in full is due at the time of each service. I clearly understand and agree that all services rendered to me may be charged directly to me, and that I am personally responsible for full payment. I understand that even if I suspend or terminate treatment, any fees for professional services rendered to me or to my dependent up to the point of termination will be immediately due and payable. I acknowledge that I am responsible for any outstanding fees for services provided to me by the clinic. Any other arrangements that may involve a payment plan or payment deferral of any kind must be made in writing with the office manager or business manager of the Practice. Verbal agreements are not acceptable or binding. I acknowledge that the Practice reserves the right to charge a fee if I fail to attend or cancel the scheduled appointment without providing the Practice 24-hour prior notice. I further acknowledge that the Practice reserves the right to reschedule my appointment if I am more than 15 minutes late to a scheduled appointment. Refund Policy The provider of services works with each client to discuss treatment options and their objectives, and to thoroughly review likely outcomes, benefits, and risks associated with each treatment. Once services are purchased, they will not be refunded. However, to ensure our clients always receive the greatest experience, unused service values (cash equivalent for the remaining amount of a treatment package) can be applied to any other service for which the client is clinically eligible as determined by the provider of services. Cash Equivalents are not transferable. For Skin Care Products, all sales are final. However, should the client have a reaction to one of the skin products, it can be returned for a full refund within 7 days of purchase. All injectable treatment sales (Botox, Juvederm, Radiesse, Restylane, Perlane, and Sculptra) are final; refunds or credits cannot be offered once treatment is completed.

IMPORTANT: PLEASE READ CAREFULLY By purchasing or receiving peptide therapy, you acknowledge and agree to the following terms: 1. Research and Development (R&D) Use Only: The peptides used in our therapies are classified as Research and Development (R&D) substances. They are intended to stimulate the body’s natural hormone production and may not be approved by the FDA for all uses. These peptides are not FDA-approved for direct use in clinical applications such as anti-aging or body composition improvement. However, they are widely used off-label for their potential benefits in growth hormone stimulation and other therapeutic effects. 2. Off-Label Use: Peptide therapy is considered off-label by the FDA when used for purposes other than the indications for which they were originally developed. We prescribe these peptides under the guidance of licensed medical professionals in compliance with state laws. Your healthcare provider has determined that peptide therapy may benefit your health needs based on your medical history, assessment, and clinical evaluation. 3. Individual Results May Vary: The effectiveness of peptide therapy varies from patient to patient. Not all individuals will experience the same benefits or results. The use of peptide therapy should be discussed in detail with your healthcare provider to ensure that it is appropriate for you. 4. Potential Side Effects: As with any therapy, peptides may cause side effects, including but not limited to headaches, fatigue, nausea, or localized injection site reactions. These effects may be temporary or require adjustments to your dosage or therapy schedule. Please discuss any side effects with your healthcare provider. 5. Legal Compliance: You acknowledge that peptide therapy is being provided in compliance with local, state, and federal regulations, including those regarding off-label drug use. We comply with all relevant laws regarding the sale and administration of peptides, and your provider will ensure that all legal requirements are met for your safety. 6. Storage and Handling: Peptides require proper storage and handling to maintain their integrity. We ensure that the peptides are stored under the required conditions, including refrigeration if necessary.

I, the undersigned, consent to receiving peptides as part of my treatment plan. I understand and acknowledge the following: 1. Nature of Treatment: I am aware that some peptides are Research and Development (R&D) medications and may not be approved by the FDA for all uses. I understand that these peptides are prescribed off-label for purposes such as growth hormone stimulation, anti-aging, and muscle or fat loss. 2. Off-Label Use: I understand that some peptide therapy is considered off-label by the FDA when used for purposes other than the indications for which the peptides were originally developed. I acknowledge that this treatment is based on clinical evidence and professional judgment. 3. Potential Benefits and Risks: I understand that peptide therapy may provide benefits such as enhanced muscle mass, reduced body fat, improved energy levels, and anti-aging effects. However, I also understand that results may vary, and not all patients will experience the same benefits. I have been informed of the potential side effects, including but not limited to headaches, dizziness, fatigue, or localized injection site reactions. 4. Alternative Treatments: I acknowledge that there may be alternative treatments available for my condition and that I have been given the opportunity to discuss these options with my healthcare provider. 5. Informed Decision: I confirm that I have had the opportunity to ask questions regarding peptide therapy, its potential benefits and risks, and the nature of the treatment. I understand that I may stop the therapy at any time, and I will inform my healthcare provider if I experience any side effects or concerns during treatment. 6. No Guarantee of Results: I understand that the results of peptide therapy are not guaranteed and that each patient’s response to treatment can vary based on individual health, genetics, and lifestyle factors. 7. Compliance with Instructions: I agree to follow all instructions provided by my healthcare provider regarding the administration of peptide therapy, including proper injection technique, dosage, and any other necessary guidelines. 8. Legal Compliance: I acknowledge that this treatment is being provided in accordance with local, state, and federal laws, and I am fully aware of the off-label nature of peptide therapy.