This agreement between (“patient “) and Prime Medical Group establishes guidelines and conditions required for the use of hormone replacement therapy (“HRT”) involving DEA “controlled” or “scheduled” medications. Prime Medical Group and patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient / practitioner relationship. Adverse side effects and / or physical / psychological dependence may develop after use of these medications and therefore, these agents are prescribed with caution.

The patient agrees and accepts to the following conditions:

1. I understand that the medications I am receiving or will receive are prescribed for me based on diagnoses derived from my submitted medical history, and the results of lab work and a physical examination. The medications are to be used exclusively for treatment of hormonal deficiencies and related medical conditions in accordance with applicable state and federal laws.

2. I understand and agree that no medical treatment or medication provided to me by Prime Medical Group will be used for the purpose of bodybuilding, performance enhancement or physical appearance.

3. I certify that the answers I provide to the health questions on the Health History form and otherwise to Prime Medical Group’s affiliated physicians’ or laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.

4. I will not attempt to obtain HRT medications from any other health care practitioner without disclosing my current medical usage of HRT or other medications. I understand that it may be against the law to do so.

5. I have discussed and understand the risks and benefits associated with HRT. I will immediately report and adverse side effects related to the use of my HRT to Prime Medical Group and discontinue use until advised to resume usage by Prime Medical Group. I voluntarily assume any and all possible risks which may be associated with HRT.

6. I understand that representatives of Prime Medical Group and / or Licensed Physicians Assistants are available for questions and / or concerning during normal business hours throughout the course of my treatment.

7. I agree that HRT medications furnished by Prime Medical Group are for my personal use only and for no other purpose. I will not share, sell or trade medications. I will safeguard my medications from loss or theft and will be responsible for their safekeeping.

8. I will be able to purchase the medications from the pharmacy designated by Prime Medical Group and the pharmacy will send medications directly to me. I understand I have the right to purchase my medications from any pharmacy of my choice. If I choose to obtain medications from a pharmacy of my own choice, I must notify Prime Medical Group in writing of my intention to do so and include the name of the pharmacy in my request.

9. I agree and understand that federal regulations prohibit the return of prescribed medications.

10. I understand that HRT treatment and medications are not covered by health insurance. I agree that all services and medications provided by Prime Medical Group or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid or other third party payer.

11. I agree that the Prime Medical Group patient / physician relationship is not intended to replace the existing patient / physician relationship with my current primary care provider (PCP) and the treatment provided by Prime Medical Group will be in conjunction with the care provided by my current PCP.

12. I agree that Prime Medical Group only treats patients over the age of 30 with documented symptoms of hormone deficiencies (Hypogonadism, testicular hypofunction and Adult Growth Hormone Deficiency). No prescription will be provided unless a clinical need exists based on required lab work, physician consolation and current health history through either patient’s personal physician or a Prime Medical Group affiliated physician. Agreement to lab work does not automatically qualify patient to clinically necessity and prescription of HRT.

This agreement between myself (patient) and Prime Medical Group. Establishes guidelines and conditions required for use of hormone replacement therapy (HRT) involving DEA “controlled” or “scheduled” medications. Prime Medical Group LLC., and (patient) agree that these guidelines and conditions are an essential factor in maintaining a successful patient / physician relationship. Adverse side effects and / or physical / psychological dependencies may develop after repeated use of these medications and therefore, these agents are prescribed with caution.

The patient accepts and agrees to the following conditions:

1. I understand that the medical treatment offered by Prime Medical Group and their physician(s) is not accompanied by any claims, guaranteed, promises or warranties.

2. I understand that the medications I have purchased are prescribed for me based on diagnoses derived from my submitted medical history, blood / lab work, and physical examination. They are to be used exclusively for treatment of these diagnoses.

3. I will not attempt to obtain “scheduled” hormone replacement therapy medications illegally or from any other healthcare practitioner without disclosing my current medication usage. I understand that it’s against the law to do so.

4. I will immediately report adverse side effects to the use of my medications to Prime Medical Group and discontinue use until advised to resume usage by Prime Medical Group.

5. I understand that the Prime Medical Group Physician (MD) and / or Licensed Nurse Practitioner are available for questions and / or concerns during normal business hours throughout the course of my treatment.

6. I will safeguard my medications from loss or theft and will be responsible for their safekeeping.

7. I agree that these medications are for my personal use only and no other purpose and I will not share, sell or trade my medications.

8. I agree that I will use my medications at the prescribed rate and dosage and will keep the medications in its respective labeled container.

9. I agree and understand that federal regulations prohibit the return of prescribed medications.

10. I agree that if I do any IM or SQ injections with a Prime medical professional, I will not hold Prime Medical or any affiliate, independent contractor or employee liable for any reactions to medications.

11. I agree to contact Prime Medical Group 4-6 weeks into the start of my therapy (and every 6 months thereafter) to arrange for any follow-up blood testing and / or an office visit / consultation as required by the Prime Medical Group Physician.

12. I agree and understand that my fees include a one hundred dollar appointment deposit which will be applied to the cost of my examination, blood work or therapy. To cancel an appointment, I must email my cancellation request to my patient care coordinator at least 48 hours prior to my scheduled appointment time or the $100 deposit will not be refunded.

13. I agree that the Prime Medical Group patient / physician relationship is not intended to replace the existing patient / physician relationship with my current primary care provider (PCP) and my Prime Medical Group treatment will be in conjunction with the care provided by my current PCP.

As required by the HIPAA Privacy Regulations, Prime Medical Group. May not use or disclose your protected health information without your authorization.

1. I hereby authorize Prime Medical Group or any of its employees to use or disclose my Patient Health Information to the following person(s), entity(ies), or business associated with this office (List laboratories, physicians that will receive information)

2. Patient Health information authorized to be disclosed: Lab Work, medical history, physician examinations, diagnoses on therapies, telemedicine encounters and tele-health encounters

3. For the specific purpose of: Bio-identical hormone therapy, Andropause Treatment, Menopause Treatment and Hormone Deficiency Treatment

4. I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.

5. Unless otherwise revoked, this Authorization will expire one year from request date.

6. I understand that I have the right to: a) Revoke this authorization by sending written notice to Prime Medical Group. and that revocation will not apply to information that has already been released in response to this authorization. b) Inspect a copy of Patient Health information being used or disclosed under federal law. c) Refuse to sign this authorization. d) Receive a copy of this authorization. e) Restrict what is disclosed with this authorization.

7. I understand that my refusal to sign this document will not affect my treatment, payment, enrollment in a health plan, or eligibility for benefits merely because I do not provide authorization to use or disclose protected patient health information.

8. By signing below, I understand and acknowledge that: a) I have read and understand this Authorization b) If I have any questions about disclosure of my protected information, I may contact my patient manager at Prime Medical Group - 312-554-5013

Thank you for your interest in Prime Medical Group, LLC. A company that provides Hormone Replacement Therapy (“HRT”). Individuals seek our medical treatments to replace hormones to improve overall health and well-being.

Before we can provide HRT, Prime Medical Group requires the following:

A. Acceptable results of laboratory tests.

B. Verification of access to primary care physician with whom you have had recent (within the preceding 12 months) physical examination (copy of the physical examination is required).

C. An office visit to Prime Medical Group affiliated physician and / or telemedicine counter with a Prime Medical Group affiliated physician.

D. Completion of all Prime Medical Group, LLC. paperwork.

Often individuals who are referred to us have previously received or are currently using medication from other physicians or HRT companies who may or may not follow the same medical evaluation or treatment protocols as we do. In some cases, where inappropriate medications, dosage levels or protocols were provided, an individual’s Medical Directors, affiliated physicians and physician extenders take no responsibility and assume no liability for an individual’s participation in any prior HRT program. Prime Medical Group, LLC. Does not use or condone the use of performance enhancement protocols or cyclical hormone therapies.

By signing this waiver you are holding Prime Medical Group, LLC. (its employees, physicians, agents and associates) harmless for any damages and liability including without limitation, attorneys fees and costs at all levels of trial and appeal related to health issues that are present or may arise in the future from previous (whether disclosed or undisclosed to Prime Medical Group, PLLC) HRT therapies, medication or protocols.