Patient Agreement & Understanding of HRT Weight Loss and Lab Levels Reporting

(Telehealth or Brick-and-Mortar)

Date: {{current_date}}

Patient Information

• **Patient Name: {{patient_first_name}} {{patient_last_name}} {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Date of Birth: {{patient_birthdate}}** {{patient_input}}

Understanding of HRT and Weight Loss

I understand Hormone Replacement Therapy is NOT a weight loss program. I understand proper caloric intake, diet and exercise are the only ways proven to decrease unwanted weight. I understand weight loss can be supported by medical services and nutritional advice offered by professionals of the entities listed below however it is ultimately the patient's responsibility to monitor daily caloric intake and perform moderate exercise to safely lose weight.

Please initial below if you agree with the previous statement: {{patient_input}}

Understanding of Lab Levels

I understand and have been allowed to ask questions about the differences in normal and optimal lab levels. Normal lab levels are often a wide range set by the lab companies such as LabCorp, Quest and others based on the general population of adults with similar age demographics. These normal ranges may vary from what our medical professionals consider optimal based on patient medical surveys, symptoms, etc. As a patient, I fully release Body Shapes Medical Management, LLC, a.k.a. ennu, its medical entities listed below, medical personnel and officers, owners, and directors. I have been allowed to review the actual lab report, am fully informed on the risks and benefits, have been allowed to ask questions and have a proper understanding of normal versus optimal lab levels.

Please initial below if you agree with the previous statement: {{patient_input}}

Signatures

Patient Signature: {{patient_input}} Date: {{current_date}}

Medical Personnel Signature: {{patient_input}} Date: {{current_date}}

Medical Services Provided by Primary Medical of KY, PSC, Primary Medical of Indiana, P.C., Elite Health Services of Ohio, P.A., CO

Patient Agreement & Understanding 2025.04.21

Form Complete