Injectables Therapy Consent Form

Patient Name: *

Date of Birth: *

Date:

Jun 16, 2026

This document is intended to serve as confirmation of informed consent for the administration of intravenous therapy, intramuscular injection and subcutaneous injection (“Injectables Therapy”) to Patient by a duly licensed healthcare practitioner contracted with Degree Wellness and its affiliates. This disclosure is intended to inform Patient so that Patient can decide whether to give or withhold their consent to undergo Injectables Therapy.

Injectables Therapy is the administration of vitamins, minerals, amino acids, anti-oxidants, herbal extracts, certain drugs, peptides and their analogs, and other medicines directly into the bloodstream through placement of a catheter or needle into a vein, into muscle or into tissue between muscle and skin.

Risks and side effects of Injectables Therapy include: (i) discomfort, bruising and pain at the site of injection; (ii) inflammation of the vein used for injection, phlebitis and infiltration; (iii) severe allergic reaction, anaphylaxis, cardiac arrest and death; (iv) slight bleeding once the catheter or needle is removed; (v) a warming or burning sensation at the site of injection and/or along the vein in which medicine(s) are being administered; (vi) hemolytic anemia/shock in patients with G6PD deficiency; (vii) general malaise and fatigue post-treatment; (viii) dizziness, feeling faint or changes in blood pressure and blood sugar during or following treatment; (ix) nausea or headaches; (x) muscular spasms, weakness or fatigue; and (xi) local thrombophlebitis. Please inform your healthcare practitioner immediately if any of these symptoms occur.

Injectables Therapy is not intended to diagnose, treat, cure or prevent any disease. This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. Injectables Therapy is considered experimental, and has been offered to you in the belief that it is of potential benefit and its use may improve your overall health. Accordingly, the standards and practices in administration of Injectables Therapy may change. There is no guarantee that Injectables Therapy will temporarily or permanently cure or alleviate hangovers, effects of altitude sickness, muscle soreness, dehydration, viral illness, fatigue, aesthetic conditions, obesity and excess weight, signs of aging or any other bodily affliction.

PLEASE INITIAL BELOW:

I assume full liability for any adverse effects that may result from the non-negligent administration of the Injectables Therapy. If I seek medical treatment for any side effect or reaction it will be at my own expense.

I understand and agree to adhere to the treatment schedule and attend the follow-up visitations set by my healthcare practitioner to permit observation and study of my progress.

I understand that I may suspend or terminate my treatment at anytime by informing my healthcare practitioner.

I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the Injectables Therapy, and agree to hold Degree Wellness Franchise, LLC, its contractors, franchisees, employees, partners, or agents (together, “Degree Wellness”) harmless regarding any complications or side effects I experience during or following the Injectables Therapy. The risks involved and the possibilities of complications have been explained to me.

*************ARBITRATION AGREEMENT—READ CAREFULLY**********

It is understood and agreed by DEGREE WELLNESS and Patient, as a recipient of services, that any legal dispute, controversy, demand, or claim that arises out of or relates to the services provided to me by DEGREE WELLNESS or any other service provided by DEGREE WELLNESS to me shall be resolved exclusively by binding arbitration to be conducted at a place agreed upon by the parties, or in the absence of such agreement, at the office of Provider Legal, in accordance with the American Health Lawyers Association (AHLA) Alternative Dispute Resolution Service Rules of Procedure for Arbitration, which are hereby incorporated into this agreement.

It is understood that any dispute as to medical malpractice (whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompletely rendered) will be determined by submission to arbitration and not in a court of law or before a jury.

It is the intent of the parties that this agreement cover all existing or subsequent claims or controversies, whether in tort, contract, or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to the treatment or services provided or not provided by any franchisee, employee, independent contractor, physician, association, partner, or agent affiliated with DEGREE WELLNESS to a patient. This party includes causes of action that might be brought on behalf of me by a spouse, heir, child (born or unborn), guardian, or parent.

I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer-reviewed publications and therefore may be considered medically unnecessary or not currently indicated.

I have truthfully answered all questions in the Intake Form regarding my medical history and have informed the health care practitioner of any known allergies to drugs or other substances, or of any past reactions to anesthetics. I have informed the healthcare practitioner of all current medications, supplements and any street or recreational drugs. I understand that failing to inform the staff about my medical issues and/or drug use can lead to serious complications.

I hereby acknowledge that I understand that my medical insurance coverage, including Medicare and Medicaid, may not pay for this non-covered service, and that all services ancillary to this treatment may be also non-covered services and non-reimbursable. I agree to be responsible for payment at the time of service for all services, including non-covered services.

I understand that a medical record will be kept of the health services provided to me. This record will be kept private, secure and confidential in accordance with applicable federal and state laws and regulations, and will not be released to others unless so directed by my healthcare practitioner or unless it is required by law.

I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee. I understand that my medical record will be kept for a minimum of three, but no more than seven years, after the date of my last visit.

I understand that I will be administered prescriptions from compounding pharmacies, which may be ordered in my name as well as office-use prescriptions.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. I can request further explanation and information of the treatment. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent.

I am aware that other unforeseeable complications could occur. I do not expect the healthcare practitioner to anticipate and/or explain all risks and possible complications. I rely on the healthcare practitioner to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

I understand that Degree Wellness has the right to refuse to provide this non-emergent voluntary Injectables Therapy service to anyone for any valid legal reason so long as that refusal is not based upon discriminatory reasons. Degree Wellness may refuse service if patient’s presence interferes with the safety and well-being of other patrons, the patient and/or the establishment itself. Refusal may occur prior to receiving treatment or after treatment has commenced but proper notice has been provided to the patient.

My signature below confirms that: (1) I have read and understand the information provided on this form and agree to the foregoing, including the arbitration provision; (2) the treatment set forth above has been adequately explained to me by my healthcare practitioner; (3) I have received all the information and explanation I desire concerning the treatment; and (4) I am 18 years or older and of sound mind.

I hereby authorize the following treatment: administration of intravenous, intramuscular and subcutaneous vitamins, minerals, amino acids, anti-oxidants, herbal extracts, certain drugs, peptides and their analogs, and other medicines.

Patient Signature*

Jun 16, 2026

Date

Patient Guardian Signature (if applicable)

Relationship to Patient*

HIPAA NOTICE OF PRIVACY PRACTICES

At Degree Wellness, we understand that health information about you is very personal and we are mandated by the Health Insurance Portability and Accountability Act (“HIPAA”) to protect your health information. We create a record of the care and services you receive from us, and this record helps to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by us, and informs you about the ways in which we may use and disclose information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

Degree Wellness Franchise, LLC, its contractors, franchisees, employees, partners, or agents (together, “Degree Wellness”) will take every reasonable action to protect your health care information including the protection of your verbal, written, and electronic protected health information (“e-PHI”) using all commercially reasonable means necessary while ensuring that the information is readily available to the providers that deliver your health care. “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. Degree Wellness implements appropriate administrative, technical, and physical safeguards to protect your health information across the company from unintended or unauthorized use, disclosure, modification or loss.

Uses and Disclosures of Protected Health Information for Treatment: Your PHI may be used and disclosed by Degree Wellness and others outside of our offices that are involved in the delivery of health care services and benefits. Your protected health information may also be used and disclosed to pay your health care bills and to support Degree Wellness operations.

Following are examples of the types of uses and disclosures of your protected health care information that we are permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made.

Treatment
Payment
Health Care Operations
Appointment Reminders
Uses and Disclosures of PHI based upon your written authorization
Required by law
Public Health Activities
Communicable Diseases
Health Oversight
Abuse or Neglect
FDA
Legal Proceedings
Law Enforcement
Coroners, Funeral Directors and Organ Donation
Research
Military Activity and National Security
Workers' Compensation
Security Officials for Inmates
Others Involved in Your Health Care
Disaster Relief
Deceased Individuals
If it is in Your Best Interest

Your Rights Regarding Health Information About You: Following are your rights with respect to your protected health information. You may exercise any of these rights by contacting us as described at the end of this Notice.

• The right to inspect and/or copy your protected health information.

• The right to request a restriction of your protected health information.

• The right to restrict release of information for certain services.

• The right to request and receive confidential communications.

• The right to have Degree Wellness amend your PHI.

• The right to receive accounting of certain disclosures we have made, if any of your PHI.

• The right to a breach notification.

• The right to obtain a paper copy of this notice from us.

We Are Required By Law To:

• Make sure that health information that identifies you is kept private.

• Give you this Notice of our legal duties and privacy practices with respect to health information about you.

• Follow the terms of the Notice that is currently in effect.

Your Medical Records: The original copy of your and/or electronic medical record is the property of Degree Wellness. You may request a copy of your records to be transferred by completing a medical records release form. As allowed by applicable state law, there will be a fee for providing you with this service. We require 14 business days from the date of your request to prepare and send your records unless the records are for urgent of life-threatening health issues.

Changes to this Notice: We reserve the right to change this Notice. We will post a copy of the current notice in our facility with the current effective date.

Complaints: If you have a question about this Notice, or you wish to exercise your rights described in this Notice, or you believe your privacy rights have been violated, you may contact us at: Degree Wellness, Attention: Medical Records, 200 Riverside Ave., #8, Jacksonville, FL 32202 or (904) 343-9694. For complete, detailed information regarding privacy laws, visit www.cms.gov/hipaa. All complaints must be submitted in writing. You will not be penalized for filing a complaint. A complaint may also be filed with the U.S. Department of Health and Human Services.

Permission to Share your Health Information: We are required to follow certain federal guidelines and laws regarding the confidentiality of your personal health information. One of these prevents us from discussing anything in your medical file with anyone other than yourself or other medical personnel involved in your care. If you would like us to discuss lab results or other personal information with your significant other, family members, or any other individuals, please fill in their name and relationship to you in the area below:

Acknowledgement of Receipt of the Degree Wellness HIPAA NOTICE OF PRIVACY PRACTICES:

I understand that Degree Wellness operates a network of locations, which may be managed by different professional entities and medical directors. If I travel between locations, my health information, including charts and treatment records, may be shared with other Degree Wellness network locations to facilitate your treatment. This sharing allows clinical staff at the treatment location to access my relevant medical history.

By signing this form, I acknowledge that I have received this “HIPAA Notice of Privacy Practices” (the “Notice”). This Notice describes in detail how Degree Wellness might use or disclose my protected health information. The Notice also discusses my rights and Degree Wellness's duties with respect to my protected health information. I have had the right to review the Notice before signing this acknowledgment.

By signing this form, I further acknowledge that medical information collected at Degree Wellness will be kept securely in line with applicable state and federal regulations.

Patient Signature*

Jun 16, 2026

Date

Injectables H&P Form

CONTACT DETAILS

Personal Information:

Name *

Sex *

Address *

City *

State *

Zip Code *

Mobile Tel *

Work Tel

Email *

Best way to contact you? *

May we leave messages at home or work? *

Yes No

Primary Care Physician *

Tel

Emergency Contact Information:

Name *

Relationship *

Tel *

¹* By providing your email, you are hereby agreeing to receive email reminders, health updates, promotions, etc. You can notify us at any time to unsubscribe.

HISTORY

Healthcare Practitioners:

Please list all other healthcare practitioners you have seen in the past 6 months:

Tel:

Reason:

Tel:

Reason:

Tel:

Reason:

Health Concerns:

Please list your primary health concerns, in order of importance:

Date of onset:

Medications:

Please list all prescription and over the counter medications you are taking or have taken in the past 3 months:

Date Started:

Dose:

Date Started:

Dose:

Date Started:

Dose:

Date Started:

Dose:

Please list all supplements you are taking (e.g. vitamins, herbal medicines, etc.) or have taken in the past 3 months:

Date Started:

Dose:

Date Started:

Dose:

Date Started:

Dose:

Date Started:

Dose:

Please list any allergies, sensitivities or adverse reactions (e.g. to medications, NSAIDs, immunizations, foods, chemicals, scents, pets) and what your reaction was (e.g. anaphylaxis, hives, itching, etc.):

Allergy	Reaction
*

Have you ever been diagnosed with any of the following conditions? If yes, please describe.

Condition	Yes	No	Details
Liver Disease *
Congestive Heart Failure *
Heart Disease *
Hypertension (High Blood Pressure) *
Hyperlipidemia (High Cholesterol) *
Thyroid Disorders *
Cancers *
Kidney Disease *
Kidney Stones *
Diabetes *
Bleeding / Clotting *
Hepatitis B *
Hepatitis C *
HIV *
Tuberculosis *
G6PD Deficiency *
Anxiety/Depression *
Other: *

Please list all current and past medical conditions, diagnosis, hospitalizations and surgeries:

Nutrition & Exercise:

Do you follow a special diet/nutritional program (i.e. Low-Carb, Gluten-Free, Vegan)? If so, which?

Do you exercise? If so, what kind (running, pilates, weights, etc.) and how many times per week?

How much and how often do you consume the following?

Water:

Soft drinks:

Coffee/Tea:

Alcohol:

Tobacco:

Recreational Drugs:

What are your goals with nutritional IV therapy?

Have you ever had IV or injectable vitamin therapy?: *

Yes No

If yes, when was your last IV or injectable vitamin?

Have you ever experienced any adverse reactions or difficulties with previous IV therapy or injectable vitamin therapy?: *

Yes No

If yes, please describe.

Diagnostic Studies:

Date of last Physical Exam/Blood test:

Any abnormal results from blood test?

Are there any medical devices implanted in your body (e.g. pins, pacemakers)?*

Yes No

If Yes, please describe:

Is there anything else you would like to include in this form?

ACKNOWLEDGEMENTS AND CONSENT

To set clear expectations, improve communications, and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.

I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care.

I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.

To the best of my knowledge, the information that I have supplied on this form is complete and truthful. I have not misrepresented the presence, severity or cause of my health status.

Patient Signature*

Jun 16, 2026

Date