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I understand by signing this Health Care Informed Consent (“Consent”), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies. I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services. I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by my Blokes Provider. As with any other medical services, some patients do not respond to prescribed treatment. I have disclosed all my known health conditions, allergies, and medications/supplements I am taking. I understand that certain treatment options that I may receive from or medications prescribed to me by my Blokes Practice Provider can be dangerous and may result in medical care that is unnecessary if I have misrepresented my current health care condition and status. I have truthfully supplied information about my health care condition and status in response to any health related questions prior to, during any in-person examination with my Blokes Provider, and after an exam. I understand that the terms herein are contractual and not a mere recital and that I sign to agree with this document as my own free act and not of any coercion. The permissions granted herein shall begin on the date I agreed to this document and shall remain effective until terminated by me. I understand I have the right to withhold/withdraw my consent at any time by submitting a request via email to info@blokes.co I verify I have read all of the information contained in this Consent. I understand I will have the opportunity to ask my Blokes Provider about anything I have not understood up to this point. TERMS AND CONDITIONS OF PAYMENT Receipt of health care services from Blokes and a Blokes Provider and your use of the Blokes, LLC Internet Platform (the “Platform”) in connection with such health care services, constitutes an ongoing agreement to these Terms and Conditions of Payment (the “Terms and Conditions”). Capitalized terms used herein but not otherwise defined shall have the meaning given to such terms in the above Health Care Services Consent. Insurance Not Accepted; Your Responsibility for Payment. INSURANCE NOT ACCEPTED; YOUR RESPONSIBILITY FOR PAYMENT I understand and acknowledge that Blokes from whom I receive care and the pharmacies that receive prescriptions from such Blokes per the Platform, are not paid or reimbursed by managed care plans, Medicare, Medicaid or other government health care programs, or other third-party payors. Blokes does not accept insurance for such services. Except as otherwise explicitly stated herein, I will be billed directly and shall be personally responsible for payment, regardless of whether I am or will be reimbursed by a managed care plan or other third-party payer. I agree to make timely payments for all health care, laboratory and pharmacy services that are provided to me. I understand by providing my payment information on the Platform, including but not limited to any credit card information or credit card hold information for future payments, I authorize Blokes, LLC to charge the credit card or other payment method for all items and/or services I receive or are scheduled to receive from the Blokes Provider providing my care, the laboratories and the pharmacies. I understand when I receive services, from Blokes, the cost of services (including medical care, laboratory, and prescription costs remitted directly to the laboratories and pharmacy on my behalf) is calculated and services are provided on an agreed upon basis, and I will be billed for payment (even if I do not receive medical services or prescriptions in more than one month of the plan for which I am billed). I understand I have the choice to pay for my program cost upfront, in-full for the year (at significant savings), or in monthly, or every other month payments. I understand I am responsible if I cancel before my agreed upon program is completed, for a prorated cost of my program even if I discontinue as a patient before completing payment monthly or every other month plan I’ve agreed to. I understand that the cost of services, including labs, medications, are final and not refundable. This is because the cost of treatment is for professional medical services (including any blood draws) which are fully rendered at point of care. Pharmacy rules prohibit the return of medications for reimbursement because medications are packaged for you and cannot be used for another patient. I understand I will not be able to receive refunds for treatments and for medications, even if they are unused. I understand that Blokes reserves the right to discontinue service if I am delinquent on any payments, for which I am responsible. I understand and agree to provide a 30 day notice prior to stopping treatment. I agree to have a final visit with a Blokes Provider, in order to safely discontinue use of the medications used in my treatment plan. MISCELLANEOUS Any and all controversies, claims, or disputes arising out of, relating to, or resulting from these Terms and Conditions of Payment shall be subject to the arbitration provisions as set forth in the Terms & Conditions at www.blokes.co The provisions of these Terms and Conditions of Payment shall be severable, and if any provisions shall be prohibited by law, invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. The virtual consultation will be recorded by the provider to ensure protection and accuracy with HIPAA compliance and company policies. The following information is provided to assist you with making an informed decision regarding the use of testosterone or other hormone therapies (which include but are not limited to testosterone cypionate, human chorionic gonadotropin (hCG), and anastrozole) which may be prescribed to you by a Blokes practitioner during the course of your treatments. 1. Testosterone is a controlled medication with risks and benefits. Some potential benefits of testosterone and other hormone therapies include: • Improvement in energy; improvement in sexual desire; decrease in fatigue; improvement in depressive symptoms; increase in muscle mass; and increase in bone density. 2. Some known or potential risks of testosterone therapy and other hormone therapies, include (but are not limited to): • Worsening of cholesterol (in particular, “good” HDL); increases in hematocrit (blood thickness); breast tissue growth, swelling, or tenderness (gynecomastia); elevated blood pressure; water retention or swelling of arms or legs (edema); blood clots in the legs, lungs, or brain; increased risk of cardiovascular or cerebrovascular events; lowering of sperm counts, possibly to the point of infertility; acne and male pattern baldness; reduced testicular size; skin-to-skin transference to a partner or child (topical therapy); skin irritation (topical therapy); prostate cancer progression; breast cancer progression; liver dysfunction (oral therapy); potential for abuse and dependence. I understand that during the course of treatment I may or may not feel or develop any of these benefits and/or risks and that I will have the opportunity to further discuss these potential benefits and risks with my provider. Hormone therapy requires close monitoring and regular examinations during the course of my treatment. I therefore agree to have the appropriate laboratory testing and examinations as recommended. There is some risk of enhancing an existing current prostate cancer to grow more rapidly. For this reason, a prostate specific antigen blood test is to be done before starting testosterone therapy and will be conducted at a minimum each year thereafter. If there is any question about possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before improving. Testosterone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin and Hematocrit) should be done at least annually. Hormone therapy may require having a therapeutic phlebotomy performed if hematocrit levels become too high, and I agree to follow these requirements if needed. I also understand that I will only be eligible to continue receiving the medication(s) if I am up to date with my examinations, laboratory work, and any necessary therapeutic phlebotomies. I agree to proceed with treatment understanding that testosterone may cause an increase in prostate size and increase in PSA levels. Patients are required to undergo PSA blood testing and digital rectal exam (when clinically appropriate) on a routine basis as recommended by your provider. Testosterone restoration is contraindicated in patients undergoing active prostate cancer treatment or known prostate cancer (with some exceptions as agreed upon by patient and provider). Aromatase Inhibitors (Anastrozole) utilization: Although the prime indication for these types of medications is in the treatment of breast cancer in women, there is increasing utilization of this medication in men. Aging men, men who are overweight, and those who are genetically predisposed can have “estrogen excess” due to converting (aromatization) too much of their testosterone to estrogen. Our fat cells contain the enzyme “aromatase” which promotes this conversion. This estrogen conversion can lower a man’s testosterone levels but also cause estrogen to spike to higher levels causing negative consequences and side effects. Estrogen excess can cause gynecomastia (breast enlargement), hot flashes and night sweats, infertility, impotence, mood changes, prostate enlargement and increased risk for prostate cancer. Peptides are small chains of amino acids that can have biological activity. They are mostly naturally occurring. Some peptides are FDA approved for the treatment of certain diseases. Other peptides used clinically are prepared by duly registered compounding pharmacies complying with all state and federal laws. Peptides can be administered in various presentations, including but not limited to oral, intravenous, subcutaneous, intramuscular and intranasal routes. As with any other drug, peptide therapies can have side effects, including but not limited to: nausea, vomiting, fever, injection site reactions (pain, rash, bleeding), Allergies, including life threatening allergies, and any additional side effects not listed.

Receipt of health care services from Blokes and a Blokes Provider and your use of the Blokes, LLC Internet Platform (the “Platform”) in connection with such health care services, constitutes an ongoing agreement to these Terms and Conditions of Payment (the “Terms and Conditions”). Capitalized terms used herein but not otherwise defined shall have the meaning given to such terms in the above Health Care Services Consent. Insurance Not Accepted; Your Responsibility for Payment INSURANCE NOT ACCEPTED; YOUR RESPONSIBILITY FOR PAYMENT I understand and acknowledge that Blokes from whom I receive care and the pharmacies that receive prescriptions from such Blokes per the Platform, are not paid or reimbursed by managed care plans, Medicare, Medicaid or other government health care programs, or other third-party payors. Blokes does not accept insurance for such services. Except as otherwise explicitly stated herein, I will be billed directly and shall be personally responsible for payment, regardless of whether I am or will be reimbursed by a managed care plan or other third-party payer. I agree to make timely payments for all health care, laboratory and pharmacy services that are provided to me. I understand by providing my payment information on the Platform, including but not limited to any credit card information or credit card hold information for future payments, I authorize Blokes, LLC to charge the credit card or other payment method for all items and/or services I receive or are scheduled to receive from the Blokes Provider providing my care, the laboratories and the pharmacies. I understand when I receive services, from Blokes, the cost of services (including medical care, laboratory, and prescription costs remitted directly to the laboratories and pharmacy on my behalf) is calculated and services are provided on an agreed upon basis, and I will be billed for payment (even if I do not receive medical services or prescriptions in more than one month of the plan for which I am billed). I understand I have the choice to pay for my program cost upfront, in-full for the year (at significant savings), or in monthly, or every other month payments. I understand I am responsible if I cancel before my agreed upon program is completed, for a prorated cost of my program even if I discontinue as a patient before completing payment monthly or every other month plan I’ve agreed to. I understand that the cost of services, including labs, medications, are final and not refundable. This is because the cost of treatment is for professional medical services (including any blood draws) which are fully rendered at point of care. Pharmacy rules prohibit the return of medications for reimbursement because medications are packaged for you and cannot be used for another patient. I understand I will not be able to receive refunds for treatments and for medications, even if they are unused. I understand that Blokes reserves the right to discontinue service if I am delinquent on any payments, for which I am responsible. MISCELLANEOUS Any and all controversies, claims, or disputes arising out of, relating to, or resulting from these Terms and Conditions of Payment shall be subject to the arbitration provisions as set forth in the Terms & Conditions at www.blokes.co The provisions of these Terms and Conditions of Payment shall be severable, and if any provisions shall be prohibited by law, invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. I understand that by signing this form, I am agreeing to the foregoing Health Care Services Consent and Terms and Conditions of Payment.

Effective Date: November 4, 2019
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. We will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. 1. Uses and Disclosures of Protected Health Information That May Be Made Without Your Authorization or Opportunity to Agree or Object Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your health care provider. Following are examples of the types of uses and disclosures of your protected health information that your health care provider is permitted to make. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician or other provider to whom you have been referred to ensure that the provider has the necessary information to diagnose or treat you. Payment: Your protected health information may be used and disclosed to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. Health Care Operations: We may use or disclose your protected health information in order to support the business activities of your health care provider. These activities include, but are not limited to, quality assessment and compliance activities, employee review activities, training and licensing. Business Associate: We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our business. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. Certain Marketing Activities: We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you. Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. Public Health Authorities: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made to a public health authority for the purpose of preventing or controlling disease or preventing or reporting child abuse or neglect. We may also disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Health Oversight Agencies: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Victim of Abuse or Neglect: We may disclose your protected health information to a government authority if we believe that you have been a victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements and limitations of applicable federal and state laws. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for certain law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our business, and (6) in the case of a medical emergency (not on our business’s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes. Research: We may disclose your protected health information to researchers in certain circumstances. For example, we may disclose such information when the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Avert Imminent Threat to Health or Safety: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security:When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs. Inmates: We may use or disclose your protected health information if you are a lawful inmate of a correctional facility or other custodial institution in certain circumstances. For example, we may use or disclose such information if the institution or facility represents that such information is necessary for your care, or for the health or safety of you, other inmates, or facility staff. 2. Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object: We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your provider may, using professional judgment, determine whether the disclosure is in your best interest. Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. 3. Uses and Disclosures of Protected Health Information Requiring Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. This includes but is not limited to any use or disclosure of your psychotherapy notes (as defined by HIPAA), as well as the use of your protected health information for marketing activities that require patient authorization under HIPAA and/or applicable state law. You may revoke any such authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization, but please understand that we are unable to take back any disclosures already made with your authorization. 4. Your Rights: Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, except for restriction requests pertaining to disclosures to health plans for payment or health care operations purposes for items or services paid for in full by you. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer. You may have the right to request that your provider amend your protected health information maintained in a designated record set. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations, and other permissible uses or disclosures exempted from such accountings by applicable laws and regulations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. 5. Complaints You may complain to us or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by us. More information about this complaint process is available at https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html. You may also file a complaint with us by notifying our Privacy Officer of your complaint. You can reach our Privacy Officer by calling our office at 720-828-8596. We will not retaliate against you for filing a complaint. If you are the parent or personal representative of the Patient, you acknowledge on behalf of the Patient that you have received or been given an opportunity to receive the Blokes, LLC Notice of Privacy Practices.

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with a provider. 1) Nature of Telemedicine Consultation: During the telemedicine consultation: a) Details of you and/or your medical history, examinations, and laboratory tests will be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. b) Physical examination of you may take place. c) Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission. d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit. 2) Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws. 3) Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and state law apply to information disclosed during this telemedicine consultation. 4) Risks and Benefits. The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician. My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.

The following information is provided to assist you with making an informed decision regarding the use of testosterone or other hormone therapies (which include but are not limited to testosterone cypionate, human chorionic gonadotropin (hCG), and anastrozole) which may be prescribed to you by a Blokes practitioner during the course of your treatments. Please review the information below and ask any questions you have about it.

Testosterone is a controlled medication with risks and benefits. Some potential benefits of testosterone and other hormone therapies include:
- Improvement in energy; improvement in sexual desire; decrease in fatigue; improvement in depressive symptoms; increase in muscle mass; and increase in bone density.
Some known or potential risks of testosterone therapy and other hormone therapies, include (but are not limited to):
- Worsening of cholesterol (in particular, “good” HDL); increases in hematocrit (blood thickness); breast tissue growth, swelling, or tenderness (gynecomastia); elevated blood pressure; water retention or swelling of arms or legs (edema); blood clots in the legs, lungs, or brain; increased risk of cardiovascular or cerebrovascular events; lowering of sperm counts, possibly to the point of infertility; acne and male pattern baldness; reduced testicular size; skin-to-skin transference to a partner or child (topical therapy); skin irritation (topical therapy); prostate cancer progression; breast cancer progression; liver dysfunction (oral therapy); potential for abuse and dependence.

I understand that during the course of treatment I may or may not feel or develop any of these benefits and/or risks and that I will have the opportunity to further discuss these potential benefits and risks with my provider. Hormone therapy requires close monitoring and regular examinations during the course of my treatment. I therefore agree to have the appropriate laboratory testing and examinations as recommended. There is some risk of enhancing an existing current prostate cancer to grow more rapidly. For this reason, a prostate specific antigen blood test is to be done before starting testosterone therapy and will be conducted at a minimum each year thereafter. If there is any question about possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before improving. Testosterone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin and Hematocrit) should be done at least annually. Hormone therapy may require having a therapeutic phlebotomy performed if hematocrit levels become too high, and I agree to follow these requirements if needed. I also understand that I will only be eligible to continue receiving the medication(s) if I am up to date with my examinations, laboratory work, and any necessary therapeutic phlebotomies. I understand and agree to provide a 30 day notice prior to stopping treatment. I agree to have a final visit with a Blokes Provider, in order to safely discontinue use of the medications used in my treatment plan.

Agree to All HEALTH CARE SERVICES CONSENT I understand by signing this Health Care Informed Consent (“Consent”), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies. I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services. I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by my Blokes Provider. As with any other medical services, some patients do not respond to prescribed treatment. I have disclosed all my known health conditions, allergies, and medications/supplements I am taking. I understand that certain treatment options that I may receive from or medications prescribed to me by my Blokes Practice Provider can be dangerous and may result in medical care that is unnecessary if I have misrepresented my current health care condition and status. I have truthfully supplied information about my health care condition and status in response to any health related questions prior to, during any in-person examination with my Blokes Provider, and after an exam. I understand that the terms herein are contractual and not a mere recital and that I sign to agree with this document as my own free act and not of any coercion. The permissions granted herein shall begin on the date I agreed to this document and shall remain effective until terminated by me. I understand I have the right to withhold/withdraw my consent at any time by submitting a request via email to info@blokes.co I verify I have read all of the information contained in this Consent. I understand I will have the opportunity to ask my Blokes Provider about anything I have not understood up to this point. TERMS AND CONDITIONS OF PAYMENT Receipt of health care services from Blokes and a Blokes Provider and your use of the Blokes, LLC Internet Platform (the “Platform”) in connection with such health care services, constitutes an ongoing agreement to these Terms and Conditions of Payment (the “Terms and Conditions”). Capitalized terms used herein but not otherwise defined shall have the meaning given to such terms in the above Health Care Services Consent. Insurance Not Accepted; Your Responsibility for Payment. INSURANCE NOT ACCEPTED; YOUR RESPONSIBILITY FOR PAYMENT I understand and acknowledge that Blokes from whom I receive care and the pharmacies that receive prescriptions from such Blokes per the Platform, are not paid or reimbursed by managed care plans, Medicare, Medicaid or other government health care programs, or other third-party payors. Blokes does not accept insurance for such services. Except as otherwise explicitly stated herein, I will be billed directly and shall be personally responsible for payment, regardless of whether I am or will be reimbursed by a managed care plan or other third-party payer. I agree to make timely payments for all health care, laboratory and pharmacy services that are provided to me. I understand by providing my payment information on the Platform, including but not limited to any credit card information or credit card hold information for future payments, I authorize Blokes, LLC to charge the credit card or other payment method for all items and/or services I receive or are scheduled to receive from the Blokes Provider providing my care, the laboratories and the pharmacies. I understand when I receive services, from Blokes, the cost of services (including medical care, laboratory, and prescription costs remitted directly to the laboratories and pharmacy on my behalf) is calculated and services are provided on an agreed upon basis, and I will be billed for payment (even if I do not receive medical services or prescriptions in more than one month of the plan for which I am billed). I understand I have the choice to pay for my program cost upfront, in-full for the year (at significant savings), or in monthly, or every other month payments. I understand I am responsible if I cancel before my agreed upon program is completed, for a prorated cost of my program even if I discontinue as a patient before completing payment monthly or every other month plan I’ve agreed to. I understand that the cost of services, including labs, medications, are final and not refundable. This is because the cost of treatment is for professional medical services (including any blood draws) which are fully rendered at point of care. Pharmacy rules prohibit the return of medications for reimbursement because medications are packaged for you and cannot be used for another patient. I understand I will not be able to receive refunds for treatments and for medications, even if they are unused. I understand that Blokes reserves the right to discontinue service if I am delinquent on any payments, for which I am responsible. I understand and agree to provide a 30 day notice prior to stopping treatment. I agree to have a final visit with a Blokes Provider, in order to safely discontinue use of the medications used in my treatment plan. MISCELLANEOUS Any and all controversies, claims, or disputes arising out of, relating to, or resulting from these Terms and Conditions of Payment shall be subject to the arbitration provisions as set forth in the Terms & Conditions at www.blokes.co The provisions of these Terms and Conditions of Payment shall be severable, and if any provisions shall be prohibited by law, invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. The virtual consultation will be recorded by the provider to ensure protection and accuracy with HIPPA compliance and company policies. The following information is provided to assist you with making an informed decision regarding the use of testosterone or other hormone therapies (which include but are not limited to testosterone cypionate, human chorionic gonadotropin (hCG), and anastrozole) which may be prescribed to you by a Blokes practitioner during the course of your treatments. 1. Testosterone is a controlled medication with risks and benefits. Some potential benefits of testosterone and other hormone therapies include: • Improvement in energy; improvement in sexual desire; decrease in fatigue; improvement in depressive symptoms; increase in muscle mass; and increase in bone density. 2. Some known or potential risks of testosterone therapy and other hormone therapies, include (but are not limited to): • Worsening of cholesterol (in particular, “good” HDL); increases in hematocrit (blood thickness); breast tissue growth, swelling, or tenderness (gynecomastia); elevated blood pressure; water retention or swelling of arms or legs (edema); blood clots in the legs, lungs, or brain; increased risk of cardiovascular or cerebrovascular events; lowering of sperm counts, possibly to the point of infertility; acne and male pattern baldness; reduced testicular size; skin-to-skin transference to a partner or child (topical therapy); skin irritation (topical therapy); prostate cancer progression; breast cancer progression; liver dysfunction (oral therapy); potential for abuse and dependence. I understand that during the course of treatment I may or may not feel or develop any of these benefits and/or risks and that I will have the opportunity to further discuss these potential benefits and risks with my provider. Hormone therapy requires close monitoring and regular examinations during the course of my treatment. I therefore agree to have the appropriate laboratory testing and examinations as recommended. There is some risk of enhancing an existing current prostate cancer to grow more rapidly. For this reason, a prostate specific antigen blood test is to be done before starting testosterone therapy and will be conducted at a minimum each year thereafter. If there is any question about possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before improving. Testosterone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin and Hematocrit) should be done at least annually. Hormone therapy may require having a therapeutic phlebotomy performed if hematocrit levels become too high, and I agree to follow these requirements if needed. I also understand that I will only be eligible to continue receiving the medication(s) if I am up to date with my examinations, laboratory work, and any necessary therapeutic phlebotomies. I agree to proceed with treatment understanding that testosterone may cause an increase in prostate size and increase in PSA levels. Patients are required to undergo PSA blood testing and digital rectal exam (when clinically appropriate) on a routine basis as recommended by your provider. Testosterone restoration is contraindicated in patients undergoing active prostate cancer treatment or known prostate cancer (with some exceptions as agreed upon by patient and provider). Aromatase Inhibitors (Anastrozole) utilization: Although the prime indication for these types of medications is in the treatment of breast cancer in women, there is increasing utilization of this medication in men. Aging men, men who are overweight, and those who are genetically predisposed can have “estrogen excess” due to converting (aromatization) too much of their testosterone to estrogen. Our fat cells contain the enzyme “aromatase” which promotes this conversion. This estrogen conversion can lower a man’s testosterone levels but also cause estrogen to spike to higher levels causing negative consequences and side effects. Estrogen excess can cause gynecomastia (breast enlargement), hot flashes and night sweats, infertility, impotence, mood changes, prostate enlargement and increased risk for prostate cancer. Peptides are small chains of amino acids that can have biological activity. They are mostly naturally occurring. Some peptides are FDA approved for the treatment of certain diseases. Other peptides used clinically are prepared by duly registered compounding pharmacies complying with all state and federal laws. Peptides can be administered in various presentations, including but not limited to oral, intravenous, subcutaneous, intramuscular and intranasal routes. As with any other drug, peptide therapies can have side effects, including but not limited to: nausea, vomiting, fever, injection site reactions (pain, rash, bleeding), Allergies, including life threatening allergies, and any additional side effects not listed.
AUTHORIZATION AND CONSENT TO PARTICIPATE IN TELEMEDICINE/TELEHEALTH CONSULTATION The purpose of this form is to obtain your consent to participate in a telemedicine consultation with a provider. 1) Nature of Telemedicine Consultation: During the telemedicine consultation: a) Details of you and/or your medical history, examinations, and laboratory tests will be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. b) Physical examination of you may take place. c) Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission. d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit. 2) Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws. 3) Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and state law apply to information disclosed during this telemedicine consultation. 4) Risks and Benefits. The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician. My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above. HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: November 4, 2019
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. We will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. 1. Uses and Disclosures of Protected Health Information That May Be Made Without Your Authorization or Opportunity to Agree or Object Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your health care provider. Following are examples of the types of uses and disclosures of your protected health information that your health care provider is permitted to make. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician or other provider to whom you have been referred to ensure that the provider has the necessary information to diagnose or treat you. Payment: Your protected health information may be used and disclosed to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. Health Care Operations: We may use or disclose your protected health information in order to support the business activities of your health care provider. These activities include, but are not limited to, quality assessment and compliance activities, employee review activities, training and licensing. Business Associate: We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our business. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. Certain Marketing Activities: We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you. Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. Public Health Authorities: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made to a public health authority for the purpose of preventing or controlling disease or preventing or reporting child abuse or neglect. We may also disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Health Oversight Agencies: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Victim of Abuse or Neglect: We may disclose your protected health information to a government authority if we believe that you have been a victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements and limitations of applicable federal and state laws. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for certain law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our business, and (6) in the case of a medical emergency (not on our business’s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes. Research: We may disclose your protected health information to researchers in certain circumstances. For example, we may disclose such information when the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Avert Imminent Threat to Health or Safety: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs. Inmates: We may use or disclose your protected health information if you are a lawful inmate of a correctional facility or other custodial institution in certain circumstances. For example, we may use or disclose such information if the institution or facility represents that such information is necessary for your care, or for the health or safety of you, other inmates, or facility staff. 2. Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object: We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your provider may, using professional judgment, determine whether the disclosure is in your best interest. Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. 3. Uses and Disclosures of Protected Health Information Requiring Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. This includes but is not limited to any use or disclosure of your psychotherapy notes (as defined by HIPAA), as well as the use of your protected health information for marketing activities that require patient authorization under HIPAA and/or applicable state law. You may revoke any such authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization, but please understand that we are unable to take back any disclosures already made with your authorization. 4. Your Rights: Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, except for restriction requests pertaining to disclosures to health plans for payment or health care operations purposes for items or services paid for in full by you. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer. You may have the right to request that your provider amend your protected health information maintained in a designated record set. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations, and other permissible uses or disclosures exempted from such accountings by applicable laws and regulations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. 5. Complaints You may complain to us or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by us. More information about this complaint process is available at https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html. You may also file a complaint with us by notifying our Privacy Officer of your complaint. You can reach our Privacy Officer by calling our office at 702-674-0143. We will not retaliate against you for filing a complaint. If you are the parent or personal representative of the Patient, you acknowledge on behalf of the Patient that you have received or been given an opportunity to receive the Blokes, LLC Notice of Privacy Practices.

I understand by signing this Health Care Services Consent (“Consent”), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.

I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care.

I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services.

I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by my Blokes Provider. As with any other medical services, some patients do not respond to prescribed treatment.

I have disclosed all my known health conditions, allergies, and medications/supplements I am taking. I understand that certain treatment options that I may receive from or medications prescribed to me by my Blokes Practice Provider can be dangerous and may result in medical care that is unnecessary if I have misrepresented my current health care condition and status. I have truthfully supplied information about my health care condition and status in response to any health related questions prior to, during any in-person examination with my Blokes Provider, and after an exam.

I understand that the terms herein are contractual and not a mere recital and that I sign to agree with this document as my own free act and not of any coercion. The permissions granted herein shall begin on the date I agreed to this document and shall remain effective until terminated by me. I understand I have the right to withhold/withdraw my consent at any time by submitting a request via email to info@blokes.co

I verify I have read all of the information contained in this Consent. I understand I will have the opportunity to ask my Blokes Provider about anything I have not understood up to this point.

TERMS AND CONDITIONS OF PAYMENT
Receipt of health care services from Blokes and a Blokes Provider and your use of the Blokes, LLC Internet Platform (the “Platform”) in connection with such health care services, constitutes an ongoing agreement to these Terms and Conditions of Payment (the “Terms and Conditions”). Capitalized terms used herein but not otherwise defined shall have the meaning given to such terms in the above Health Care Services Consent. Insurance Not Accepted; Your Responsibility for Payment.

INSURANCE NOT ACCEPTED; YOUR RESPONSIBILITY FOR PAYMENT
I understand and acknowledge that Blokes from whom I receive care and the pharmacies that receive prescriptions from such Blokes per the Platform, are not paid or reimbursed by managed care plans, Medicare, Medicaid or other government health care programs, or other third-party payors. Blokes does not accept insurance for such services. Except as otherwise explicitly stated herein, I will be billed directly and shall be personally responsible for payment, regardless of whether I am or will be reimbursed by a managed care plan or other third-party payer.

I agree to make timely payments for all health care, laboratory and pharmacy services that are provided to me. I understand by providing my payment information on the Platform, including but not limited to any credit card information or credit card hold information for future payments, I authorize Blokes, LLC to charge the credit card or other payment method for all items and/or services I receive or are scheduled to receive from the Blokes Provider providing my care, the laboratories and the pharmacies. I understand when I receive services, from Blokes, the cost of services (including medical care, laboratory, and prescription costs remitted directly to the laboratories and pharmacy on my behalf) is calculated and services are provided on an agreed upon basis, and I will be billed for payment (even if I do not receive medical services or prescriptions in more than one month of the plan for which I am billed). I understand I have the choice to pay for my program cost upfront, in-full for the year (at significant savings), or in monthly, or every other month payments. I understand I am responsible if I cancel before my agreed upon program is completed, for a prorated cost of my program even if I discontinue as a patient before completing payment monthly or every other month plan I’ve agreed to. I understand that the cost of services, including labs, medications, are final and not refundable. This is because the cost of treatment is for professional medical services (including any blood draws) which are fully rendered at point of care. Pharmacy rules prohibit the return of medications for reimbursement because medications are packaged for you and cannot be used for another patient. I understand I will not be able to receive refunds for treatments and for medications, even if they are unused. I understand that Blokes reserves the right to discontinue service if I am delinquent on any payments, for which I am responsible.

I understand and agree to provide a 30 day notice prior to stopping treatment. I agree to have a final visit with a Blokes Provider, in order to safely discontinue use of the medications used in my treatment plan.

MISCELLANEOUS
Any and all controversies, claims, or disputes arising out of, relating to, or resulting from these Terms and Conditions of Payment shall be subject to the arbitration provisions as set forth in the Terms & Conditions at www.blokesstg.wpenginepowered.com The provisions of these Terms and Conditions of Payment shall be severable, and if any provisions shall be prohibited by law, invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. The virtual consultation will be recorded by the provider to ensure protection and accuracy with HIPPA compliance and company policies.

I understand that by signing this form, I am agreeing to the foregoing Health Care Services Consent and Terms and Conditions of Payment.

INFORMED CONSENT FOR HORMONE THERAPY

Please review the information below and ask any questions you have about it.

1. Testosterone is a controlled medication with risks and benefits. Some potential benefits of testosterone and other hormone therapies include:
• Improvement in energy; improvement in sexual desire; decrease in fatigue; improvement in depressive symptoms; increase in muscle mass; and increase in bone density.

2. Some known or potential risks of hormone therapy and other hormone therapies, include (but are not limited to):
• Worsening of cholesterol (in particular, “good” HDL); increases in hematocrit (blood thickness); breast tissue growth, swelling, or tenderness (gynecomastia); elevated blood pressure; water retention or swelling of arms or legs (edema); blood clots in the legs, lungs, or brain; increased risk of cardiovascular or cerebrovascular events; lowering of sperm counts, possibly to the point of infertility; acne and male pattern baldness; reduced testicular size; skin-to-skin transference to a partner or child (topical therapy); skin irritation (topical therapy); breast cancer progression; liver dysfunction (oral therapy); potential for abuse and dependence.

Hormone therapy requires close monitoring and regular examinations during the course of my treatment. I therefore agree to have the appropriate laboratory testing and examinations as recommended.

Hormone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin and Hematocrit) should be done at least annually.

Hormone therapy may require having a therapeutic phlebotomy performed if hematocrit levels become too high, and I agree to follow these requirements if needed. I also understand that I will only be eligible to continue receiving the medication(s) if I am up to date with my examinations, laboratory work, and any necessary therapeutic phlebotomies.

I certify that I have received and understand this information and had my questions answered. I also understand that I have the option to not take hormone therapy at any time.

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with a provider.

1) Nature of Telemedicine Consultation: During the telemedicine consultation: a) Details of you and/or your medical history, examinations, and laboratory tests will be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. b) Physical examination of you may take place. c) Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission. d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.

2) Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws.

3) Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and state law apply to information disclosed during this telemedicine consultation.

4) Risks and Benefits. The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.

My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.

I acknowledge receipt of Blokes Authorization and Consent to Participate in Telemedicine/Telehealth Consultation

HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: November 4, 2019
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. We will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information That May Be Made Without Your Authorization or Opportunity to Agree or Object

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your health care provider. Following are examples of the types of uses and disclosures of your protected health information that your health care provider is permitted to make.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician or other provider to whom you have been referred to ensure that the provider has the necessary information to diagnose or treat you.

Payment: Your protected health information may be used and disclosed to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

Health Care Operations: We may use or disclose your protected health information in order to support the business activities of your health care provider. These activities include, but are not limited to, quality assessment and compliance activities, employee review activities, training and licensing.

Business Associate: We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our business. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

Certain Marketing Activities: We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

Public Health Authorities: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made to a public health authority for the purpose of preventing or controlling disease or preventing or reporting child abuse or neglect. We may also disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Health Oversight Agencies: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Victim of Abuse or Neglect: We may disclose your protected health information to a government authority if we believe that you have been a victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements and limitations of applicable federal and state laws.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for certain law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our business, and (6) in the case of a medical emergency (not on our business’s premises) and it is likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers in certain circumstances. For example, we may disclose such information when the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Avert Imminent Threat to Health or Safety: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your protected health information if you are a lawful inmate of a correctional facility or other custodial institution in certain circumstances. For example, we may use or disclose such information if the institution or facility represents that such information is necessary for your care, or for the health or safety of you, other inmates, or facility staff.

2. Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object: We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your provider may, using professional judgment, determine whether the disclosure is in your best interest.

Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

3. Uses and Disclosures of Protected Health Information Requiring Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. This includes but is not limited to any use or disclosure of your psychotherapy notes (as defined by HIPAA), as well as the use of your protected health information for marketing activities that require patient authorization under HIPAA and/or applicable state law. You may revoke any such authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization, but please understand that we are unable to take back any disclosures already made with your authorization.

4. Your Rights:
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, except for restriction requests pertaining to disclosures to health plans for payment or health care operations purposes for items or services paid for in full by you.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.

You may have the right to request that your provider amend your protected health information maintained in a designated record set. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations, and other permissible uses or disclosures exempted from such accountings by applicable laws and regulations.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

5. Complaints
You may complain to us or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by us. More information about this complaint process is available at https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index. html. You may also file a complaint with us by notifying our Privacy Officer of your complaint. You can reach our Privacy Officer by calling our office at 702-674-0143. We will not retaliate against you for filing a complaint.

I acknowledge receipt of Blokes HIPAA notice of privacy practices.

If you are the parent or personal representative of the Patient, you acknowledge on behalf of the Patient that you have received or been given an opportunity to receive the Blokes, LLC Notice of Privacy Practices.

I agree to make timely payments for all health care, laboratory and pharmacy services that are provided to me. I understand by providing my payment information on the Platform, including but not limited to any credit card information or credit card hold information for future payments, I authorize Blokes , LLC to charge the credit card or other payment method for all items and/or services I receive or are scheduled to receive from the Blokes Provider providing my care, the laboratories and the pharmacies. I understand when I receive services, from Blokes , the cost of services (including medical care, laboratory, and prescription costs remitted directly to the laboratories and pharmacy on my behalf) is calculated and services are provided on an agreed upon basis, and I will be billed for payment (even if I do not receive medical services or prescriptions in more than one month of the plan for which I am billed). I understand I have the choice to pay for my program cost upfront, in-full for the year (at significant savings), or in monthly, or every other month payments. I understand I am responsible if I cancel before my agreed upon program is completed, for a prorated cost of my program even if I discontinue as a patient before completing payment monthly or every other month plan I’ve agreed to. I understand that the cost of services, including labs, medications, are final and not refundable. This is because the cost of treatment is for professional medical services (including any blood draws) which are fully rendered at point of care. Pharmacy rules prohibit the return of medications for reimbursement because medications are packaged for you and cannot be used for another patient. I understand I will not be able to receive refunds for treatments and for medications, even if they are unused. I understand that Blokes reserves the right to discontinue service if I am delinquent on any payments, for which I am responsible.

I understand that by signing this form, I am agreeing to the foregoing Health Care Services Consent and Terms and Conditions of Payment.

[{"reviewer_name":"David Maus","review_text":"\"As we get older we can lose the ability to be mentally and physically sharp. To combat this I've started taking NAD+. I work closely with Blokes to ensure everything I take is right for me.\"","reviewer_image":"https:\/\/blokes.co\/wp-content\/uploads\/2024\/03\/dmaus.jpeg"},{"reviewer_name":"Eric Hinman","review_text":"\"Not only did I see my biomarkers improve, I know I'm taking exactly what my body needs for better performance and better day to day life.\"","reviewer_image":"https:\/\/blokes.co\/wp-content\/uploads\/2024\/03\/erich.jpeg"},{"reviewer_name":"CJ Finley","review_text":"\"For years I suffered behind closed doors even though I thought I was doing all the right things. It wasn't until I started working with Blokes did I start to feel better and improve my my life.\"","reviewer_image":"https:\/\/blokes.co\/wp-content\/uploads\/2024\/03\/CJ-.jpeg"}]

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