PLEASE BE INFORMED:

I hereby permit Dr. Garrett Wdowin, any associated medical professional of Wdowin Naturopathic Inc and working in conjuction with Vitality Rx, and any associate/employee providing medical services on their behalf to perform the following medical treatment or procedure (hereafter the “procedure”):

• • IM Administration
• • Phlebotomy
• • Pharmaceutical Interventions
• • Hormonal Therapy

The procedure has been explained to me and I have been told the reasons why the procedure may benefit me. The risks of the procedure have also been explained to me. In addition, I have been told that the procedure may not have the result that I expect. I have also been told about other possible treatments for my condition and what might happen if no treatment is received.

I understand that in addition to the risks (including yet not limited to the following – allergic reaction, pain at injection site, bruising, blood clots, hair loss, prostate enlargement, heart disease, cancer, stroke, and death) described to me about this procedure there are risks that may occur with any medical procedure. I am aware that the practice of medicine carries risks and that I have not been given any guarantees about the results of the procedure or program.

I have had enough time to discuss my condition and treatment with my health care providers and all of my questions have been answered to my satisfaction. I believe I have enough information to make an informed decision and I agree to have the procedure.

If something unexpected happens and I need additional or different treatment(s) from the treatment I expect, I agree to accept any treatment that is necessary.

I understand that diet and exercise play a major role in my health and for optimal results I should follow a healthy diet and exercise multiple times a week.

I understand that it has been recommended I donate blood while undergoing testosterone replacement therapy. Donating blood will be an important step to maintain healthy blood viscosity.

I understand that with hormone supplementation there are possible risks and complications if I do not comply with the recommended dosages. I understand that I may be in charge of administering the hormones and supplements prescribed to me. I will conform and comply with the recommended dosages and methods of administration.

I understand that the initial blood tests will be performed to establish my baseline hormone levels. I agree to comply with reasonable requests for follow up testing, which I will be made aware of the cost before any such testing takes place, to assure proper monitoring of my hormone levels.

I agree to report to the medical staff any adverse reaction or problem that might be related to my hormone therapy. I understand that with testosterone replacement therapy, as with any therapy, there may be side effects. Side effects of testosterone replacement include, yet not limited to, mood changes, acne, prostate enlargement, breast enlargement or testicular shrinkage, stroke, heart disease, pulmonary embolism and all cause of death.

I understand the role of Wdowin Naturopathic is for the management of my hormone replacement only. I agree that I will be under the care of another health care provider for other medical conditions and will have yearly physical exams with a physician. I agree that the medical staff at Wdowin Naturopathic will not take the place of my personal medical provider in this regard.

PLEASE BE INFORMED:

ATTENTION: You are not agreeing to purchase anything or committing to a therapy by initiating and signing this paperwork. This is merely a doctor-patient arbitration agreement

Article 1: Agreement to Arbitrate:

It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Muse be Arbitrated:

It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the doctors including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the doctor and the doctor’s partners, associates, association, corporation or partnership and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the doctor to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the doctor, any fee dispute, whether or not subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law:

A demand for arbitration must be communicated in writing to all parties. Each part shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such party’s pro rata share or the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or the expenses incurred by a party for such party’s own benefit.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure.

Article 4: General Provisions:

All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the California Code of Civil Procedure provisions relating to arbitrations shall govern the arbitration.

Article 5: Revocation:

This agreement may be revoked by written notice delivered to the doctor within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Retroactive Effect:

If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

INFORMED CONSENT

I hereby permit Dr. Garrett Wdowin, any associated medical professional of Wdowin Naturopathic Inc and working in conjuction with Vitality Rx, and any associate/employee providing medical services on their behalf to perform the following medical treatment or procedure (hereafter the “procedure”):

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE:By signing this contract you are agreeing to have any medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See article 1 of this contract.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices and your rights concerning your health information. We must follow the privacy practices that are described in the Notice while it is in effect. This Notice takes effect 10/1/2015 and will remain in effect until we replace it.

As permitted by law we reserve the right to change our privacy practices and terms of this Notice at any time. We reserve the right to make the changes in our privacy practices and the new terms of Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make significant changes in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

TREATMENT: We may use or disclose your health information to a physician or other healthcare provider who is providing treatment to you.

PAYMENT: We may use and disclose your health information to obtain payment for services we provide to you.

HEALTHCARE OPERATION: We may use and disclose your health information for treatment in connection with our healthcare operations. Healthcare operations includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

YOUR AUTHORIZATION:In addition to our use of your health information for treatment, payments or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us this authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we do so.

PERSONS INVOLVED IN YOUR CARE: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

MARKETING HEALTH-RELATED SERVICES: We will not use your health information for marketing communications without your written authorization.

REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law.

ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible perpetrator/victim of abuse, neglect, or domestic violence or the possible perpetrator/victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders such as voicemail messages, postcards, letters, emails etc.

NATIONAL SEQURITY: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose, to authorized federal officials, health information required for lawful intelligence, counter-intelligence or other national security. We may disclose to correctional institution or lawful inmate or patient under certain circumstances.

PATIENT RIGHTS

ACCESS: You have the right to look at copies of your health information, with limited exceptions. You may request that we provide copies of your health information yet these requests must be made in writing. You will be charged a $40 fee for materials, staff time, and postage if you request it be mailed to you.

DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last three years, but not before July 2, 2010. If you request this accounting more than once in a 12- month period, you will be charged a $30 fee for response of these additional requests.

RESTRICTION: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we accept, we will abide by our agreement, except in an emergency.

ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative names or to alternative locations. These requests must be submitted in writing and must specify the means or location of your request.

AMENDMENT: You have the right to request that we amend your health information. Your request must be in writing and it must explain why the information should be amended. We may deny your request under certain circumstances.

ELECTRIC NOTICE: If you receive this Notice on our Web site or by e-mail you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS: If you want more information about our privacy practices or have question or concerns, please contact us at Wdowin Naturopathic Inc, 2121 East Coast Hwy, suite 210, Corona del Mar, CA 92625, or by phone at (949)-891-1693.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or have us communicate with you by alternative means or at alternative locations, you may contact us using the contact information listed above.