HRT Consent Packet (Telehealth or Brick-and-Mortar)

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., C.O., Primary Medical of IN, P.C.

Medical Services Agreement

Name: {{patient_first_name}} {{patient_last_name}} {{patient_input}}

Date of Birth: {{patient_birthdate}} {{patient_input}}

Agreement Date: {{current_date}}

Date: {{current_date}}

Term:

Patient agrees that medical service is ongoing and continuous until patient notifies company in writing with 60 days' notice prior to next scheduled payment date. Service charges will occur monthly on the Agreement date. For patients who have previously prepaid for medical services, the patient card-on-file will be charged the monthly amount per the SERVICES CHARGE SHEET. If savings are available via a pre-paid option, then patient may be eligible to elect this option in the future.

Medical Service Fees:

Patient agrees to pay the amount per the SERVICES CHARGE SHEET for services purchased. For patients who have elected not to pre-pay, services fees are subject to change with 15-day notice.

Cancellation:

Patient understands that due to medical services and active prescriptions being provided, a cancellation fee equal to two months of medical service fees will be charged upon notice of intent to cancel. Additionally, within 10 business days of cancellation notice, Patient agrees to sign the cancellation agreement AND schedule a meeting with a provider to determine termination dates of prescriptive care and transition, if any, of files.

Card Authorization:

Patient agrees to keep the CREDIT CARD AUTHORIZATION ON FILE AGREEMENT current at all times, including card expiration and account number.

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

Hormone Replacement Therapy (HRT) Member Information

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., C.O., Primary Medical of IN, P.C.

Your medical provider has prescribed hormone replacement therapy (HRT) for the purpose of reducing symptoms that may be due to low levels of testosterone, DHEA, estradiol, progesterone, thyroid and Vitamin D3 such as weight gain, loss of muscle mass, lethargy, concentration issues, short-term memory loss and decreased libido. While there are no guarantees of results from HRT, many members have experienced improvement in these symptoms. Even if your hormone levels are within normal range for your age, hormonal therapy may be prescribed to address a specific functional deficiency.

TOPICAL CREAM:

Cases of secondary exposure of testosterone have been reported in children, other adults in close proximity who are not taking testosterone, and pets. Children, pregnant women, and pets should avoid contact with unwashed or unclothed application sites in members using testosterone creams.

PELLETS:

Testosterone may be administered via subdermal pellet implants. These pellets are a natural soy-derived bioidentical testosterone inserted under the skin of the lateral buttocks to achieve a steady and consistent delivery of hormone into the bloodstream. Pellet extrusion (coming out) has been known to occur on rare occasions. In addition, there is a slight chance of a wound infection, as with any type of surgical procedure. Wound infection can be easily treated with an antibiotic, or very rarely, incision and drainage. Pellets dissolve naturally within 4 to 12 months after implantation, and should be considered irretrievable once inserted. However, in extraordinary circumstances, pellets may be removed via a minor outpatient surgical procedure. Pellets may be added if needed to achieve desired results/ blood levels.

IMPORTANT CONSIDERATIONS:

For Men:

• In large doses Testosterone may lower your sperm count. While this effect may be temporary, men who are planning to have children are recommended to produce sperm samples for freezing as a precaution before beginning testosterone therapy because it can affect ability to conceive.

Potential Side Effects:

• Enlarged or painful breasts; nipple tenderness
• If you already have enlargement of your prostate gland, your signs and symptoms can get worse while using Testosterone. This can include: increased urination at night, trouble starting your urine stream, having to pass urine many times during the day, having an urge to go to the bathroom right away, having a urine accident, being unable to pass urine or weak urine flow.

THYROID:

Hair loss: This side effect is usually temporary as your body adjusts to the medication. Stop the Medication and call your provider if you experience any serious side effects including but not limited to: Allergic reaction (rash, itching and swelling especially in face or tongue, severe dizziness, trouble breathing, increased sweating, sensitivity to heat, mental/mood changes, fatigue, diarrhea, shaking/tremor, headache, shortness of breath, chest pain, fast/pounding/irregular heartbeat, swelling in hands/ankles/feet or seizures.

I have read and understood all of the above information. I understand the risks and benefits of the proposed treatment, and have asked and received answers to my questions.

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

Witness (Provider) Signature: {{patient_input}} Date: {{current_date}}

Hormone Therapy General Consent

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., C.O., Primary Medical of IN, P.C.

I request and consent to the administration of hormone replacement therapy (HRT), which may consist of Testosterone, Estradiol and other bio-identical hormones prescribed by my medical provider.

It is important that you understand the risks and benefits associated with Hormone Replacement Therapy (HRT) before beginning or continuing treatment. HRT is not a new area of medicine, however the treatment modalities may involve innovative therapies and there are no guarantees with respect to the treatment prescribed. You should also be aware of alternatives to HRT, including not receiving HRT treatment, leaving hormone levels where they are, and treating age-related diseases and symptoms as they appear. It is important that you consider the information we provide and discuss the information carefully with your provider. Be sure that you are doing what is right for you. If you are unsure, then you should refuse and/or discontinue treatment.

I have read and understood all of the above consent conditions. I acknowledge that I have received additional more specific information pertinent to my treatment so that I fully understand the risks and benefits of the proposed treatment, and that it is my responsibility to read and understand this information and to ask questions about anything I do not understand fully.

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

Witness (Provider) Signature: {{patient_input}} Date: {{current_date}}

Off Label Consent

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., C.O., Primary Medical of IN, P.C.

Check the box next to "Agree" if you agree with the following statement:

☐ Agree - "This is my consent to begin treatment for Hormone Replacement Therapy"

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

Witness (Provider) Signature: {{patient_input}} Date: {{current_date}}

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

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., C.O., Primary Medical of IN, P.C.

Lab Levels Understanding

Check the box next to "Agree" if you agree with the following statement:

☐ Agree - 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.

Weight Loss Understanding

Check the box next to "Agree" if you agree with the following statement:

☐ Agree - 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.

Initials: {{patient_input}}

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

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

Patient Agreement & Understanding 2025.05.07

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