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

The following terms govern my purchase of and participation in the Medical Weight Loss Program, including any Semaglutide or Tirzepatide (GLP-1) treatment plan (the “Program”), and represent a binding agreement between the undersigned patient (“I,” “me,” “my,” or “Client”) and ELEO, a DBA of Custom Health Centers, Inc., together with KetalityRX (collectively, the “Company,” “we,” “us,” or “our”).

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. I affirm that I have stated all of my known medical conditions and answered all questions honestly, and I agree to keep the Company updated as to any changes in my medical profile during the Program.

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 the Company 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.

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

6. 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), 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.

7. Program Acknowledgments

I acknowledge the following statements to be true:

• No guaranteed results. As with any medical treatment, it is not possible to guarantee that the Program will be successful within a specified time frame, or at all. Individual results vary.

• Refund policy. The Company incurs costs for each Client in order to provide the Program. Program fees and consultation fees are non-refundable once the corresponding services have been provided. Medications are non-refundable once shipped from the compounding pharmacy, because compounded medications are prepared for an individual patient and cannot be restocked or resold. If a medication does not work for me, or I cannot stay on a medication due to side effects, the Company will suggest alternatives — up to and including ordering an alternative medication approved by my prescribing provider — but amounts paid for services already rendered and medications already shipped are not refundable. If the pharmacy is unable to fill a prescription before shipment, the Company will offer an account credit, a clinically appropriate substitute, or a refund of the amount paid for that medication.

• Products subject to change. Program products, including the supplements and prescribed medications therein, are subject to change. The Company reserves the right to make improvements, updates, and changes to Program products at any time during the term of this Agreement, subject to my prescribing provider’s approval of any medication change.

• Membership cancellation. If my Program is billed as a recurring membership, I may cancel by written request at least fourteen (14) days before my next billing date, as set out in the Invoice Terms & Conditions.

8. Lifestyle Transformation Process

I acknowledge that the Medical Weight Loss Program is a lifestyle transformation that takes time, effort, and focus from the participating Client. The Program and its coaches aim to make weight loss an effective and sustainable process; however, I will be asked to make lifestyle changes to accomplish my goals, and failure to follow the recommended lifestyle changes will decrease my results.

I must schedule follow-up appointments with my own medical doctor for evaluation during and after the Program. Individuals who lose weight often need their medications adjusted — including medications for high blood pressure, diabetes, and other conditions — and I am responsible for coordinating with my own medical doctor regarding any such adjustments. If I am currently taking medication, I will continue to follow my medical doctor’s instructions and stay on my medications unless my doctor directs otherwise.

All materials and recommendations contemplated by this Agreement are intended to assist me in my personal weight loss effort. The Company — including, but not limited to, Dr. Thomas Nabity, MD, Dr. Jason Olafsson, DC, and Dr. Bradley Krawczyk, DC — will not give me medical advice, medical treatment, or medical diagnosis beyond the medical weight loss plan advised for me. The information provided by the Company should not be interpreted as a substitute for consultation, evaluation, or treatment by my primary care physician, and I am strongly advised to seek the advice of my own physician before beginning any weight loss effort or regimen. If I have questions about any health concern, I should seek medical assistance, and if I am not satisfied with the advice of my current physician, I have the right to obtain another medical opinion.

9. Informational Materials; No Warranties

ALL GENERAL HEALTH-RELATED AND MEDICAL INFORMATION AND CONTENT CONTAINED IN ANY MATERIALS PROVIDED TO ME (“MATERIALS”) IS MADE AVAILABLE ON AN “AS IS” AND “AS AVAILABLE” BASIS, WITH ALL FAULTS, AND IS PROVIDED WITHOUT ANY WARRANTIES, GUARANTEES, OR REPRESENTATIONS OF ANY KIND OR PURPOSE. The Materials are for general information purposes only and are not a substitute for professional medical advice from my physician. UNDER NO CIRCUMSTANCES SHOULD I USE ANY OF THE INFORMATION CONTAINED IN THE MATERIALS, OR ANY PRODUCTS RECOMMENDED OR PROVIDED TO ME, TO DETERMINE WHETHER TO DELAY SEEKING MEDICAL TREATMENT OR PROFESSIONAL MEDICAL ADVICE. The Company makes no representations concerning the effectiveness of any treatment, course of action, test, product, or service referenced in any Materials.

10. Limitation of Liability

In the event of breach or default on the part of the Company, the Company’s liability is limited to a refund of the fees paid by the Client for services not yet rendered and medications not yet shipped at the time of the breach or default. The Company is not liable for any defect, claim, liability, loss, or expense asserted or incurred as a result of the breach, default, negligence, or wrongdoing of the Client or the Client’s agent. Nothing in this section limits any liability that cannot be limited under applicable law.

11. Issue Resolution; Governing Law; Dispute Resolution

If I have any issue with the Program, its elements, or my results, I agree to contact ELEO first so that the Company and I can attempt to resolve the issue directly — the Company’s weight loss coaches and staff will address questions and specific needs regarding the Program. Nothing in this Agreement restricts my right to post an honest review of my experience.

This Agreement is governed by the laws of the State of Michigan. Any dispute between the Company and the Client relating to this Agreement, including its interpretation and the adequacy of any performance under it, shall first be submitted to mediation. If the dispute is not resolved through mediation, it shall be resolved by binding arbitration before a single arbitrator mutually acceptable to the Client and the Company. The arbitrator’s decision shall be final and binding on the parties and enforceable in any court of appropriate jurisdiction. In any mediation, arbitration, or litigation arising from this Agreement (including collections), the prevailing party shall be entitled to recover its reasonable attorney fees, arbitrator fees, and costs. If, for any reason, any dispute arising out of or relating to this Agreement is subject to litigation, that litigation shall be conducted exclusively in Oakland County, Michigan, and the parties consent to that jurisdiction and venue.

12. Severability

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

13. Effective Date; Program Commencement

This Agreement is binding on the date the parties’ signatures are affixed. My weight loss Program should commence within thirty (30) days of this Agreement. If an extension is required, the extension should begin within thirty (30) days of completion of the Program.

14. 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.

15. Off-Label Use and Compounded Medications

15.1 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.

15.2 Compounded Medications

Some medications in my treatment plan — including compounded Semaglutide or Tirzepatide — 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.

16. General Provisions; Consent to Treatment

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.

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 Client 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. I give my consent for this medication/treatment to be prescribed to me and for my use of it as directed by my physician.

This Agreement 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 Agreement, including the GLP-1 Medication Consent.