WAIVER OF LIABILITY (Check the box) *

I, the undersigned, am aware that participation in the Treatment (hereafter referred to as TREATMENT) may include activities that may cause injury and are dangerous. I acknowledge that participation in this TREATMENT has the following non-exhaustive list of particular activities that bear risk from which bodily injury, without limitation, up to and including death, may occur: Allergic reactions, anaphylaxis, blood clots, bleeding, scarring, infections, adverse reaction to anesthesia (e.g., nausea, vomiting), blood clot formation, nerve damage, tissue damage, pain or discomfort, bruising, swelling, wound healing complications, respiratory complications, excessive bleeding, adverse drug interactions, numbness, psychological distress. With full knowledge of the facts and circumstances surrounding the TREATMENT, I voluntarily participate in the TREATMENT and assume the responsibilities and risks resulting from my participation, including all risk of property damage and injury to others and to myself. I agree to comply with all of the rules and conditions of participating in the TREATMENT. I am aware that in the practice of medicine, other unexpected complications and risks my Physician didn’t discuss with me may occur. I understand the proposed treatments might reveal unforeseen conditions. These conditions may result in the processed treatments changing. I have adequate applicable insurance necessary to provide for and pay any medical costs that may directly or indirectly result from my participation in the TREATMENT, or otherwise understand that I am solely responsible for any medical costs that may directly or indirectly result from my participation in the TREATMENT. I will indemnify and hold Telehealth Central LLC, Compounding Doctors, its practitioners, physicians, nurses, employees, directors, officers, agents, and registered affiliates (hereafter referred to as TELEHEALTH CENTRAL) harmless with respect to any and all claims, injuries, and costs associated with my participation in this TREATMENT. Furthermore, I acknowledge that I am solely responsible for any action that I participate in associated with this TREATMENT or around this TREATMENT, regardless if occurring before, during or after the period of the TREATMENT. I will conduct myself in a manner that is considerate of other patients and in accordance with TELEHEALTH CENTRAL’S Rules and Regulations and with any state and city laws or rules where the TREATMENT is occurring. I recognize and acknowledge that TELEHEALTH CENTRAL may record my participation and appearance in TREATMENT on any recorded medium (including, but not limited to video, audio, photos) for use in any form (including, but not limited to print, websites, blogs, internet). I authorize such recording and release TELEHEALTH CENTRAL to use my name, likeness, voice, and biographical material to exhibit or distribute such recordings in whole or part without restrictions or limitations for any educational or promotional purpose. I further release TELEHEALTH CENTRALto use material from blogs associated with TREATMENT without restrictions or limitations for any educational or promotional purpose. I am aware that if I provide a vehicle not owned and operated by the TELEHEALTH CENTRAL for transportation to, at, or from the TREATMENT site, or if I am a passenger in such a vehicle, TELEHEALTH CENTRAL is not responsible for any damage caused by or arising from my use of such transportation. Furthermore, I acknowledge that I am solely responsible for any action that I take that is outside the scope of the scheduled TREATMENT, regardless if occurring before, during or after the period of the TREATMENT. To the extent permitted by law, and in consideration for being allowed to participate in the TREATMENT, I hereby save, hold harmless, discharge and release the TELEHEALTH CENTRAL from any and all liability, claims, causes of actions, damages or demands of any kind and nature whatsoever that may arise from or in connection with my participation in any activities related to the TREAMENT, whether caused by the negligence or carelessness of TELEHEALTH CENTRAL or otherwise. It is my express intent that this Acknowledgment of Risk and Waiver of Liability shall bind my spouse, the members of my family and my estate, heirs, administrators, personal representatives and assigns. I further agree to save and hold harmless, indemnify and defend the TELEHEALTH CENTRAL from any claim by the aforementioned parties arising out of my participation in the TREATMENT. I recognize and acknowledge that TELEHEALTH CENTRAL makes no guarantees, warranties, representations, or other promises relative to the TREATMENT, and assumes no liability or responsibility for injury or property damage that I may sustain as a result of participation in the TREATMENT. I further understand and agree that this is a release of liability and indemnity agreement, and it is intended to be as broad and inclusive as permitted by law. If any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and legal effect. COVID-19 I understand that there is a risk of me contracting COVID-19 or other illnesses in any public location during my TREATMENT. I agree to not use the Facility in the event I have, or have had in the last fourteen (14) days, any symptom reasonably related to COVID-19 or have been exposed to any individual with such symptoms. If at any time after execution of this Waiver, I contract COVID-19, experience COVID-19 symptoms, or become aware that I have been exposed to any individual in the prior fourteen (14) days who has received a COVID-19 diagnosis, I shall immediately notify TELEHEALTH CENTRAL and shall not return to the Facility without authorization from TELEHEALTH CENTRAL following either (i) receipt of a negative COVID-19 test and/or (ii) completion of then-current quarantine guidelines promulgated by federal and state health agencies. TELEHEALTH CENTRAL has no duty to inform me of any individual with COVID-19 who has used the Facility. MEDICAL INFORMATION I hereby certify that, with or without accommodation,* I have no health-related reasons or problems that preclude or restrict my participation in the TREATMENT. I hereby consent to and understand myself to be solely responsible for the cost of first aid, emergency medical care, and, if necessary, admission to an accredited hospital for executing such care or treatment for injuries that I may sustain while participating in any activity associated with the TREATMENT. SIGNATURES My signature below signifies that I give my authorization and consent. This consent is for my Doctor and their associates, assisted by medical center personnel and other trained persons, and with the presence of observers, to perform the treatments and procedures described above. In signing this Acknowledgement of Risk and Waiver of Liability I hereby acknowledge and represent: (a) that I have read this document in its entirety, understand it, and sign it voluntarily; and (b) that this Acknowledgement of Risk and Waiver of Liability is the entire agreement between the parties hereto and its terms are contractual and not a mere recital.

Telehealth Services (Check the box) *

During your treatment with us you may be provided with service via Telehealth. The information below is a consent form to enable us to provide services to you in this way. Please read the information below and then to consent electronically sign your name in the space provided. Where appropriate the services you receive may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. Our practice will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services. To access telehealth consultations, you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable internet connection. The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the session provided. In addition, there may be some services for which telehealth is not appropriate or effective. Your practitioner will consider and discuss with you the appropriateness of ongoing telehealth sessions. My signature below signifies that I give my authorization and consent. In signing this Telehealth consent waiver I hereby acknowledge and represent that I have read this document in its entirety, understand it, and sign it voluntarily.

Telehealth Central

ACKNOWLEDGEMENT OF RISK

Consent Waiver