ELEO is a registered DBA of Custom Health Centers, Inc.

This Agreement is between the undersigned patient (“I,” “me,” “my,” or “patient”) and ELEO, a DBA of Custom Health Centers, Inc. (“ELEO,” “we,” “us,” or “our”). It applies to hormone replacement therapy (“HRT”) and related services provided to male and female patients, including but not limited to testosterone, thyroid hormone, estradiol, progesterone, and related supportive therapies.

1. Accuracy of Health Information

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my health. It is my responsibility to inform ELEO of any changes in my medical status, medications, or health conditions during the course of my care.

2. Agreement to Use Electronic Signatures and Electronic Documents

I agree that the electronic signatures included in this document are intended to authenticate this writing and have the same force and effect as manual signatures. “Electronic signature” means any electronic sound, symbol, or process attached to or logically associated with a record and executed and adopted by a party with the intent to sign such record, including (without limitation) typing a name or clicking a checkbox.

I agree to use electronic documents, notices, and contracts (“electronic documents”) for all future transactions and communications. Electronic documents contain the same information as paper documents, notices, and contracts. Paper documents are available at my request. If I give my consent to use electronic documents, I may later change my mind and request paper documents instead.

3. Appointment Cancellation Policy

I agree to keep all scheduled appointments and to be on time. If I cannot attend a scheduled session, I will contact ELEO to cancel and/or reschedule. There is no fee for a canceled appointment.

4. Informed Consent for Telehealth Consultations

I understand that telehealth is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual who is located at a different site than the provider. I hereby consent to ELEO providing healthcare services to me via telehealth.

I understand that the laws that protect the privacy and confidentiality of health information also apply to telehealth. ELEO delivers telehealth services through third-party technology platforms (including Kalix, Inc., GoHighLevel, Zoom, and Jotform) with which ELEO maintains business associate agreements as required by HIPAA. Data transmitted through these platforms is encrypted in transit and at rest. Telehealth appointments are not recorded, and I understand that I have the right to access any information resulting from the service, as required by law.

To join a telehealth appointment, ELEO will send me a secure link and code, or will call the phone number I provide, as part of my appointment confirmation and reminder messages, which are sent through email or text message.

I understand that telehealth services are not the same as an in-person appointment because I will not be in the same room as my healthcare provider, and my provider will not be able to perform a direct physical examination. I understand there are potential risks to this technology, including interruptions and technical difficulties, and that either ELEO or I may discontinue a telehealth appointment if the connection is not adequate for the situation. A minimum internet upload and download speed of 2 Mbps is recommended, and the quality of my connection may affect the quality of services provided.

The alternatives to telehealth services have been explained to me, and I understand that my use of this technology is voluntary. I have the right to withhold or withdraw my consent to telehealth at any time, orally or in writing, without affecting my right to future care or treatment. As long as this consent is in force, ELEO may provide healthcare services to me via telehealth without the need for me to sign another consent form.

5. Financial Policy

ELEO collects payment for care at the time services are rendered. We accept debit cards, Mastercard, Visa, American Express, and Discover. The ultimate responsibility for full payment rests with the adult patient or guarantor. If an account becomes delinquent and is referred to an attorney or collection agency, or suit is filed, the patient or guarantor will be responsible for all patient charges, reasonable attorney fees, collection expenses, and court costs.

I authorize ELEO to use and disclose the minimum necessary protected health information to banks, card networks, and financing companies, when requested, to process payment for my account, consistent with HIPAA.

Refunds. Medications are not refundable once shipped from the compounding pharmacy, because compounded medications are prepared for an individual patient and cannot be restocked or resold. If the pharmacy is unable to fill a prescription before shipment, ELEO will offer an account credit, a clinically appropriate substitute approved by the prescribing provider, or a refund of the amount paid for that medication. Consultation and service fees are non-refundable once the service has been provided. Recurring memberships may be canceled in writing at least fourteen (14) days before the next billing date, as set out in the Invoice Terms & Conditions.

If I have a concern about a charge, I agree to contact ELEO first so we can review and resolve the issue directly.

6. Informed Consent for Hormone Replacement Therapy

6.1 General

I understand that HRT is individualized medical treatment intended to restore or optimize hormone levels based on my laboratory results, symptoms, and health history. Response to therapy varies between individuals, and no specific result can be guaranteed. Ongoing laboratory monitoring and follow-up visits are a required part of treatment, and I agree to complete them as directed by my provider. I understand that failing to complete required monitoring may result in my provider pausing or discontinuing my therapy for safety reasons. I agree to promptly report new or worsening symptoms to my provider.

The sections below describe the principal known risks of the categories of hormone therapy ELEO prescribes. Only the sections applicable to my prescribed treatment plan apply to me. I understand these lists are not exhaustive, that unforeseeable complications can occur, and that I do not expect my provider to anticipate or explain every possible complication. I rely on my ELEO provider to exercise clinical judgment during the course of my treatment.

6.2 Testosterone Therapy — Male Patients

Potential risks and side effects of testosterone therapy in men include, but are not limited to:

• Increased red blood cell count (polycythemia / elevated hematocrit), which can increase the risk of blood clots and may require dose adjustment, therapeutic phlebotomy, or discontinuation.

• Suppression of natural testosterone production, testicular shrinkage, and reduced sperm production or infertility, which may be prolonged or, in some cases, permanent. Patients who wish to preserve fertility should discuss options with their provider before starting therapy.

• Acne, oily skin, fluid retention, and increased blood pressure.

• Breast tenderness or enlargement (gynecomastia) related to conversion of testosterone to estrogen.

• Worsening of pre-existing sleep apnea.

• Mood changes, including irritability or aggression.

• Prostate effects: testosterone therapy can raise PSA and may stimulate growth of pre-existing prostate cancer; periodic prostate/PSA monitoring is required as clinically indicated.

• Cardiovascular considerations: patients with existing cardiovascular disease should discuss risks and benefits with their provider; I agree to report chest pain, shortness of breath, or symptoms of stroke or blood clot immediately and to seek emergency care.

• Injection-site reactions (pain, redness, bruising, infection) for injectable formulations, and skin transfer risk to others for topical formulations.

6.3 Testosterone Therapy — Female Patients

I understand that testosterone use in women is an off-label use. Potential risks include, but are not limited to: acne and oily skin, increased facial or body hair growth, scalp hair thinning, voice deepening, enlargement of the clitoris, mood changes, and fluid retention. Some virilizing effects may be irreversible if therapy is not adjusted promptly, and I agree to report these symptoms to my provider as soon as they appear.

6.4 Estradiol / Estrogen Therapy

Potential risks of estrogen therapy include, but are not limited to: blood clots (deep vein thrombosis, pulmonary embolism), stroke, elevated blood pressure, gallbladder disease, breast tenderness, nausea, headache or migraine, fluid retention, and a potential increased risk of breast cancer with prolonged use. For patients with an intact uterus, estrogen therapy without adequate progesterone increases the risk of endometrial (uterine) overgrowth and cancer; I understand my provider may prescribe progesterone alongside estrogen for this reason. I agree to report any unexplained vaginal bleeding, breast lumps, leg swelling or pain, chest pain, or neurological symptoms immediately, and to maintain routine breast cancer screening as recommended for my age and risk profile.

6.5 Progesterone Therapy

Potential risks and side effects of progesterone include, but are not limited to: drowsiness or sedation (oral micronized progesterone is commonly taken at bedtime for this reason), dizziness, mood changes or depressed mood, breast tenderness, bloating, headache, and irregular bleeding or spotting. Some micronized progesterone formulations contain peanut oil; I agree to inform my provider of any peanut or other relevant allergy.

6.6 Thyroid Hormone Therapy

Potential risks of thyroid hormone therapy (including levothyroxine (T4), liothyronine (T3), and desiccated thyroid preparations) relate primarily to over-replacement and include, but are not limited to: rapid or irregular heartbeat, palpitations, chest pain, anxiety, tremor, insomnia, heat intolerance, weight loss, and, with prolonged over-replacement, bone density loss (osteoporosis) and atrial fibrillation, particularly in older patients. Thyroid therapy requires periodic laboratory monitoring, and I agree to complete lab work as directed and to report cardiac symptoms immediately. I understand thyroid medication should be taken as instructed relative to food and other medications and supplements, which can affect absorption.

6.7 Supportive and Adjunct Therapies

My treatment plan may include supportive or adjunct medications or supplements (for example, DHEA, medications that manage estrogen conversion, or agents that support natural hormone production). The purpose, instructions, and principal risks of any such therapy will be reviewed with me, and I may ask my provider questions about any component of my plan at any time.

6.8 Pregnancy and Breastfeeding

For female patients: I attest that I am neither pregnant nor breastfeeding, that I do not plan to become pregnant while on therapy, and that I will notify my provider immediately if I become pregnant, plan to become pregnant, or begin breastfeeding, as certain hormone therapies can cause fetal harm or are not appropriate during pregnancy or breastfeeding.

7. Lab Draw Consent

My signature on this Agreement acknowledges that:

• Blood draw involves inserting a needle into a vein and drawing one or more vials of blood.

• Alternatives to blood draw with ELEO include, but are not limited to, testing available through my primary care or specialty physician outside of ELEO.

• Potential risks of blood draw include, but are not limited to — occasionally: discomfort, bruising, and pain at the draw site; rarely: inflammation of the vein (phlebitis), fainting, metabolic disturbances, and injury; extremely rarely: severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.

• Benefits of blood draw and full panel testing include knowledge of baseline and follow-up levels of the markers on the order form reviewed with me by my ELEO provider.

I am aware that unforeseeable complications could occur, and I do not expect my ELEO provider to anticipate or explain all possible complications. I rely on my ELEO provider to exercise judgment during the course of my treatment. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. I understand that I have the right to consent to or refuse any proposed treatment at any time. My signature affirms that I have given consent for blood draw with ELEO.

8. Acknowledgment of AI-Assisted Technology

I understand that ELEO utilizes artificial intelligence (AI) technology as a clinical support tool to assist in analyzing laboratory results, generating treatment recommendations, and streamlining patient care. I acknowledge that:

• AI technology is used to assist clinical staff in reviewing bloodwork and suggesting potential treatment protocols based on my lab results and health history.

• All AI-generated recommendations are reviewed, evaluated, and approved by a licensed healthcare provider before any treatment decisions are made.

• AI does not replace the clinical judgment of my provider. My treatment plan is ultimately determined and overseen by a qualified medical professional.

• My personal health information used within these systems is handled in accordance with applicable privacy practices.

I acknowledge that I have been informed of the use of AI-assisted technology in my care and consent to its use as a supportive tool under provider supervision.

9. Off-Label Use and Compounded Medications

9.1 Off-Label Use

Some medications in my treatment plan may be prescribed for a use, dose, or patient population that the FDA has not specifically approved (“off-label” use). Off-label prescribing is a legal and common practice when, in the provider’s clinical judgment, it is medically appropriate. If a medication in my plan is prescribed off-label, I understand this and consent to its use as directed by my provider.

9.2 Compounded Medications

Some medications in my treatment plan may be compounded medications, prepared for me individually by a licensed compounding pharmacy. I understand that compounded medications are not FDA-approved drug products: the FDA does not review compounded medications for safety, efficacy, or quality before they are dispensed, although compounding pharmacies are regulated by state boards of pharmacy and applicable federal law. I consent to the use of compounded medications as prescribed by my provider.

10. GLP-1 Medication Consent

If my Program includes a GLP-1 medication (such as Semaglutide or Tirzepatide), I acknowledge the following:

• Risks. The risks of GLP-1 therapy were discussed with me. Though rare, potential risks include low blood sugar, decreased kidney function, pancreatitis, medullary thyroid cancer, multiple endocrine neoplasia syndrome type 2, gallstones, cholecystitis (gallbladder inflammation), potential risk of Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION), a higher risk of inhaling gastric contents into the lungs while under anesthesia, and worsening of diabetic retinopathy. Common side effects include nausea, vomiting, constipation, diarrhea, and reduced appetite. I understand these potential risks and agree that, for me, the potential for benefit outweighs the potential for risk. I agree to inform any anesthesia provider that I am taking a GLP-1 before any procedure requiring sedation or anesthesia.

• Self-injection. GLP-1 medications must be administered by self-injection. The risks and proper injection techniques were discussed and demonstrated. I consent to self-injection.

• Eating disorders. I attest that I do not currently have an eating disorder such as anorexia nervosa or bulimia nervosa. If I develop symptoms of an eating disorder during the Program, I agree to disclose this to my prescribing provider immediately.

• Pregnancy and breastfeeding (female patients). I attest that I am neither pregnant nor breastfeeding, and that I do not plan to become pregnant or begin breastfeeding while taking a GLP-1. I will notify my provider immediately if this changes.

• Dosing schedule and supply. I understand that if I increase my dose faster than the recommended schedule, my medication may not last the duration discussed at purchase. If I follow the recommended schedule, my supply is intended to last the duration discussed at purchase. Individual tolerance and sensitivity to the medication cannot be predicted in advance; the Company will make reasonable efforts to keep me on schedule and help me achieve the best results.

11. Governing Law and Dispute Resolution

This Agreement is governed by the laws of the State of Michigan. If I have any concern or dispute regarding my care or account, I agree to first contact ELEO so we can attempt to resolve it directly. Any dispute that cannot be resolved informally shall first be submitted to mediation, and if not resolved through mediation, shall be resolved by binding arbitration before a single arbitrator mutually acceptable to the parties. The arbitrator’s decision shall be final and binding and enforceable in any court of appropriate jurisdiction. In any arbitration or litigation arising from this Agreement, the prevailing party shall be entitled to recover its reasonable attorney fees and costs. Any litigation shall be conducted exclusively in Oakland County, Michigan, and the parties consent to that jurisdiction and venue. If any term of this Agreement is held invalid or unenforceable, the remainder shall remain in effect to the fullest extent permitted by law.

12. General Provisions

I acknowledge that the prescribing physician may use and disclose my information as necessary for the purposes of treatment, payment, and healthcare operations, in a manner consistent with HIPAA regulations and applicable requirements. I intend this consent to be continuing in nature and to remain in full force until revoked in writing. A photocopy or electronic copy of this consent shall be as valid as the original.

13. Consent to Treatment

I have read, or have had read to me, all of the above statements and understand them. I have been clearly advised of my rights and responsibilities as a patient of ELEO, including the HIPAA Notice of Privacy Practices. I have had the opportunity to ask any questions I might have about the medications and treatment being prescribed, their potential risks, and the alternatives, prior to giving my informed consent. The procedures and treatments described above have been adequately explained to me, and I have received all the information and explanation I desire. I give my consent for the medications and treatment described in my plan to be prescribed to me and for my use of them as directed by my physician.

This consent is incorporated into and made part of my ELEO health history form. My single signature on that form constitutes my agreement to, and acceptance of, every section of this document.