To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform Custom Health Centers of any changes in medical status.

Agreement to Use Electronic Signatures and Electronic Documents

I agree that the electronic signatures included in this notice are intended to authenticate this writing and to 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 contacts "electronic documents", for all future transactions and communications. Electronic documents contain the same information as paper documents, notices and contracts. Paper documents, notices and contracts are available at my request. If I give my consent to use electronic documents, I can later change your mind and request a paper agreement instead.

Cancellation Policy

I agree to keep all scheduled appointments and be on time. If I cannot attend a scheduled session, I will contact Custom Health Centers to cancel and/or reschedule. There will be no fee if the appointment is canceled before 24 hours of the scheduled appointment time. I understand if I miss or cancel with less than 24 hours of notice, then I will be charged for the full price of the appointment.

Informed Consent for Telehealth Consultations

I understand that telehealth is the use of electronic information and communication technologies by a healthcare provider for the delivery of services to an individual when he/she is located at a different site than the provider. I hereby consent to Custom Health Centers providing healthcare services to me via telehealth.

I understand that the laws that protect the privacy and the confidentiality of health information also apply to telehealth. Custom Health Centers's telehealth services are provided by Kalix, Inc., GoHighLevel, Zoom, and Jotform, all HIPAA compliant platforms.

These platforms uses a secure browser-to-browser technology without the need to download or install any software. All data, video, audio, and files are encrypted in both transit and rest. Telehealth appointments are not recorded in any way, but I understand that I have the right to access any information resulting from the service, as required by law.

To join a telehealth appointment, Custom Health Centers will send me a secure link and code as part of my appointment confirmation and appointment reminder messages, which are sent through email or text message.

I understand that telehealth services are not the same as direct in-person appointment delivery because I will not be in the same room as the healthcare provider. The inability to have direct, physical contact with my healthcare provider is a primary difference between telehealth and direct in-person service delivery.

I understand there are potential risks to this technology, including interruptions and technical difficulties. I understand that Custom Health Centers or I can discontinue the telehealth appointment if it is felt that the telehealth connections are not adequate for the situation. Good internet download and upload speed is required for quality telehealth services. The recommended minimum upload and download speeds required is 2Mbps. I can conduct an internet speed test by clicking here. I understand that the quality of my video connection may affect the quality of services provided by Custom Health Centers.

I have had the alternatives to telehealth services 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 use telehealth in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Custom Health Centers. As long as this consent is in force (has not been revoked), Custom Health Centers may provide healthcare services to me via telehealth without the need for me to sign another consent form.

Financial Policy

Custom Health Centers financial policy requires our company to collect payment for your care at the time services are rendered. We accept debit card, Mastercard, Visa, American Express, and Discover. We ask you to remember that the ultimate responsibility for full payment for our services rests with the adult patient or guarantor. If your account becomes delinquent and it becomes necessary for the account to be referred to an attorney or collection agency or suit, the patient or guarantor will be responsible for paying all patient charges, reasonable attorney fees, collection expenses, and court costs. Custom Health Centers, Inc is affiliated with multiple insurance companies and will attempt to bill out for services. In the case that your insurance provider covers the services you will only be responsible for the remaining balance.

It may become necessary to release your protected health information to financial parties, credit card entities, banks, and financing companies, when requested, to facilitate your payment. Services that are performed that are paid with a credit card, debit card, or financing third party are not eligible for payment challenges after services are provided. By signing this form, I am irrevocably consenting to allow Custom Health Centers, INC. to use and disclose my protected health information to any Credit Card Entity, Bank, or Financing company when they request such information to process an account and assist with payment.

I will not challenge such credit, debit, or financing card payments once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise, which are further addressed in the Revision Policy. I agree that this noncredit card challenge agreement is irrevocable.

Consent to Treatment

I have read through all the above information and have been clearly advised of my rights and responsibilities as a client of Custom Health Centers, including the HIPAA Notice of Privacy Practices.

GLP-1 Clause:
1. The risk of GLP-1 therapy was discussed. Though rare, potential risks included the risk of low blood sugar, decreased kidney function, pancreatitis, medullary thyroid cancer, multiple endocrine neoplasia, gall stones, cholecystitis, and diabetic retinopathy. The patient understands these potential risks and agrees that the potential for benefit outweighs the potential for risk.
2. GLP-1s must be administered by self-injection. The risks and proper injection techniques were discussed and demonstrated. Patient consents to self-injection.
3. The patient consents that they do not have an eating disorder such as anorexia or bulimia and if they were to develop symptoms of either disorder, they will disclose this to their health coach.
4. For Female patients, I consent that I am neither pregnant nor breastfeeding, and I do not plan to become pregnant or start breastfeeding while taking a GLP-1.
5. I understand that if I want to change the dosing schedule and increase the medication at a faster rate then what is recommended that the medication may not last the duration previously discussed upon purchase. If you stick to the schedule your supply will last the duration discussed upon purchase. There is no way to know how tolerant or sensitive someone will be to the medication. We will do our best to keep you on schedule and to help you achieve the best results.

Weight Loss Contract

1. Acknowledgements By You

I acknowledge the following statements to be true by placing my initials in the box below that all of the following acknowledgments will apply:

I acknowledge that I have had a consultation privately about my current health status, weight concerns, the details of the food plan, the details of the program, benefits, and requirements of the Plan conducted by Custom Health Centers and KetalityRX before signing this Agreement.
I acknowledge that I have received a consultation about my weight and about the Medical Weight Loss Plan before signing this agreement.
I acknowledge that, as with all research and development activities, it is not possible to guarantee that the performance of the Services will be successful within a specified time frame or at all.
I acknowledge that the Company incurs costs with each client in order to provide the Plan and the Company’s services. Because of this, there are NO REFUNDS given for our weight loss program. Even if a medication or supplement does not work for you or you can not stay on the medication or supplement due to side effects, we will make suggestions for alternatives, up to ordering you the alternative, but there are NO REFUNDS.
I acknowledge products are subject to change. The Program Products, including the supplements or prescribed medications therein, are subject to change without notice. CHC and KetalityRX reserve the right to make improvements, updates, and/or changes to its Program Products at any time during the term of this Agreement.
I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the health coaches updated as to any changes in my medical profile during the session and understand that there shall be no liability on the health coaches, nurses, doctors, or employees of Custom Health Centers.

2. Life Transformation Process

Client hereby acknowledges that the Medical Weight Loss Plan is a lifestyle transformation and a transformation that takes time, effort, and focus from the client participating. Our weight loss program and coaches aim to make weight loss a fast, fun, and easy process. That being said, the client will be asked to make lifestyle changes to accomplish their goals. Failure to follow the recommended lifestyle changes will decrease your desired results.
As with any diet, exercise program, fat loss program, and food management plan, there are tremendous rewards; however, Client must schedule follow-up appointments with Client’s medical doctor for evaluation. Individuals who lose fat often need their medications adjusted. Client is responsible for coordinating with his/her medical doctor as to the same. All materials and recommendations contemplated by this Agreement are intended merely to assist Client in his/her personal weight loss efforts. Company, including, but not limited to, Dr. Thomas Nabity, MD, Dr. Jason Olafsson, DC, or Dr. Bradley Krawczyk, DC will NOT give Client medical advice, medical treatment, or medical diagnosis above and beyond the medical weight loss plan advised for the client. Thus, the information generated by the Company should not be interpreted as a substitute for a client's primary care physician consultation, evaluation, or treatment. Client is vehemently urged and advised by the Company to seek the advice of their own medical physician before beginning any weight loss effort or regimen.
If you are currently taking medication, please continue to follow your medical doctor’s instructions and stay on your medication(s). However, during or after the completion of your plan, you may want to schedule a follow-up with your medical doctor to be re-evaluated. We find it to be very common that individuals who lose fat and decrease weight will often need their medications adjusted.
You are urged and advised to seek the advice of a physician before beginning any weight loss effort or regimen. This information is not meant to replace the advice of any physician. Do not rely upon any information received from anyone or any materials in our program to replace consultations or advice received by qualified health professionals regarding your own specific situation. Any information provided by Dr. Thomas Nabity, MD, Dr. Jason Olafsson, Dr. Bradley Krawczyk, Custom Health Centers, Inc., our doctors, nurses, or staff should NEVER be construed as medical advice above and beyond the advised Medical Weight Loss Plan or semaglutide plan. You agree to not hold Dr. Thomas Nabity, MD, Dr. Jason Olafsson, DC, Dr. Bradley Krawczyk, DC, or KetalityRX or Custom Health Centers, Inc. responsible for any health-related issues as a result of participating in this protocol.
If you have any questions in your mind regarding any health concern, you should seek medical assistance. If you are not satisfied with the advice of your current physician, you always have the right to obtain another medical opinion.
Additionally, if you are on medications, such as for high blood pressure, cancer and/or diabetes, or any other health condition, you agree to be monitored regularly by your physician because some medications may require adjustment during the protocol as a natural side effect resulting from weight loss with this program.

3. Additional Terms and Conditions

All general health-related and medical information and content contained in any materials provided to Client by Company is made available for informational purposes only, thus, presented “as is” and “as available” and is provided without any warranties, guarantees, or representations of any kind or purpose; again, the Company does not provide medical advice, treatment, or diagnosis of any kind beyond the advised weight loss program. All medical or health-related information contained in the materials contemplated by this Agreement is NOT intended to be a substitute for consulting a medical physician. Under no circumstances should the Client use any of the information contained in the materials contemplated by this Agreement or any products recommended or provided by the Company to determine whether Client should seek any medical treatment or professional medical advice. Furthermore, Company makes no representations concerning the effectiveness of any treatment, course of action, test, product, or service contemplated by this Agreement.

4. Limitation of liability.

In the event of breach or default on the part of Company, Company’s liability is limited to a refund of funds paid by Client at the time of breach or default. Company is not liable for any defects, claims, liability, loss, and/or expense asserted or incurred as a result of breach or default, negligence, and/or wrongdoing of Client or Client’s agent. The following terms govern your purchase and participation in the Custom Weight Loss System (“Plan”) and represent a binding agreement between you, the undersigned (sometimes referred to as “you”, “I” or “me”), and Custom Health Centers, Inc. or KetalityRX (“Company” or sometimes referred to as “us” or “we”).
The following terms govern your purchase and participation in the Custom Weight Loss System or Semaglutide or Tirzepatide (“Plan”) and represent a binding agreement between you, the undersigned (sometimes referred to as “you”, “I” or “me”), and Custom Health Centers, Inc. (“Company” or sometimes referred to as “us” or “we”).

5. DISCLAIMERS.

ALL GENERAL HEALTH-RELATED AND MEDICAL INFORMATION AND CONTENT CONTAINED IN ANY MATERIALS PROVIDED TO YOU (“MATERIALS”) IS MADE AVAILABLE ON A “AS IS” AND “AS AVAILABLE” BASIS, “WITH ALL FAULTS” AND IS BEING PROVIDED WITHOUT ANY WARRANTIES, GUARANTEES OR REPRESENTATIONS OF ANY KIND, OR PURPOSE. We do not provide medical advice of any kind or nature or any kind of medical treatment or diagnosis. All medical or health-related information contained in the Materials is not intended to be a substitute for your physician or for professional medical advice and is being provided for general information purposes only. UNDER NO CIRCUMSTANCES SHOULD YOU USE ANY OF THE INFORMATION CONTAINED IN THE MATERIALS OR ANY PRODUCTS RECOMMENDED OR PROVIDED TO YOU BY US TO DETERMINE WHETHER OR NOT YOU SHOULD DELAY SEEKING ANY MEDICAL TREATMENT, OR PROFESSIONAL MEDICAL ADVICE. We do not make any representations concerning the effectiveness of any treatment, course of action, test, product, or service referenced in any Materials other than achieving the results under our Satisfaction Guarantee.

6. Severability.

If any term, covenant, or condition of this Agreement is held invalid or unenforceable, the remainder of this Agreement shall remain in effect; each term, covenant, and condition of this Agreement shall be valid and enforceable to the fullest extent permitted by law.

7. Effective date.

This Agreement shall be binding on the date that both parties’ signature is affixed. Client’s weight loss program should commence within 30 days of this agreement. If for any reason an extension is required for the Client, the extension should begin within 30 days of completion of the weight loss program.

8. Issue Resolution

You agree that you will contact Custom Health Centers and KetalityRX if you have any issues with the program elements and/or results. Resolution will be determined between the Company and client. Social media, the Internet and any online mediums including, but not limited to, Internet forums, chat rooms, blogs, social media sites, such as Facebook, the Better Business Bureau (BBB), Google, Yelp, Yahoo are not effective tools for communicating with the Company or resolution. Additionally, if you are on medications for any medical condition, such as for high blood pressure, cancer and/or diabetes, or other health condition, you agree to be monitored regularly by your physician because some medications may require adjustment during the protocol as a natural side effect resulting from weight loss with this program. In the event that you have questions or specific needs in regard to the program, the weight loss coaches and staff will address them accordingly. We thank you for your trust and confidence. Our goal is to get your body as healthy as possible and help you reach your desired weight loss goal as effectively as possible without the use of dangerous drugs or surgery. Our system is time-tested, and the clients that gain the greatest benefit are the ones that follow the program with little to no deviation. Dispute resolution; jurisdiction and venue. This Agreement shall be governed and controlled by the laws of the State of Michigan. Any dispute between Company and Client related to this Agreement, including the interpretation of this Agreement and the adequacy of any performance under this Agreement, shall be resolved by arbitration before a single arbitrator who is mutually acceptable to Client and Company. The decision of the arbitrator on any dispute shall be final and binding on the Parties and enforceable in any court of appropriate jurisdiction. However, should it become necessary for Company to employ an attorney to enforce any of the conditions or covenants hereof, including, but not limited to, collections or arbitration, Client agrees to pay all expenses so incurred, including all attorneys' fees. Notwithstanding the aforementioned, Client and Company hereby agree to mediate any dispute related to this Agreement prior to initiating said arbitration. Yet, should it become necessary for Company to employ an attorney to enforce any of the conditions or covenants hereof, including, but not limited to, collections or mediation, Client agrees to pay all expenses so incurred, including all attorneys' and/or arbitrator's fees. If, for any reason, any dispute arising out of or relating to this Agreement shall be subject to litigation, said litigation shall be conducted exclusively in Oakland County and the Parties consent to such jurisdiction and venue.

9. Photo/Video/Testimonial Release:

I consent to Custom Health Centers and KetalityRX using any videos, pictures, written testimonials, or audio testimonials that are sent to CHC or posted on social media sites or anywhere else online in connection with the weight-loss program or the CHC supplement company for advertising or marketing purposes. I understand that I may refuse to authorize the release of any health information and that my refusal to consent to the release of my information will prevent the disclosure of such information, but will not affect the purchased services presently receive, or will receive, from Custom Health Centers, Inc. or KetalityRX. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I further understand that I have the right to revoke this authorization in writing at any time, but if I do so, it won't have any effect on any actions taken prior to my revocation. I understand that the information disclosed, or some portion l, hereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 ('HIPAA).

I hereby grant permission for the offices of Dr. Jason Olafsson, DC, Dr. Tom Nabity, MD, Dr. Brad Krawczyk, DC, Custom Health Centers, Inc., and its business partners arising in connection with the usage of your image, likeness, and/or voice.

Consent for Off-label and No-label use

I understand that the prescribing of this medication and my use of it is either an off-label (non-FDA approved) use of this medication or that the medication does not have an approved use by the FDA. Off-label use of this medication means that the FDA has not approved the use of this medication for the purposes for which the doctor has prescribed it to me.

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. This shall be done in a manner consistent with HIPAA regulations and applicable requirements. I intend this consent to be continuing in nature and that it will remain in full force until revoked in writing. A photocopy of this consent shall be considered as valid as the original. I have read or have had read to me all the above statements and understand them. I have had the opportunity to ask any questions I might have about the medication and the treatment being prescribed, any potential risks, and the alternatives prior to my informed consent. I give consent for this medication/treatment to be prescribed to me and for my use of it as directed by my physician.