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NOTICE OF PRIVACY PRACTICES
Your Lifestyle
PAYMENT DETAILS

Please Read and Acknowledge the Privacy Statement Below

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. IF YOU WOULD LIKE A COPY OF THIS NOTICE PLEASE LET US KNOW AND WE WILL BE HAPPY TO SUPPLY YOU WITH A COPY.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

2. OUR LEGAL DUTY ________________________________________________________________________________________________________________________________________________ The Law Requires us to: ________________________________________________________________________________________________________________________________________________ ✓ Keep your medical information private. ________________________________________________________________________________________________________________________________________________ ✓ Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. ________________________________________________________________________________________________________________________________________________ ✓ Follow the terms of the current notice ________________________________________________________________________________________________________________________________________________ We Have the Right to: ________________________________________________________________________________________________________________________________________________ ✓ Change our privacy practices and the terms of this notice at any time, provided the changes are permitted by law. ________________________________________________________________________________________________________________________________________________ ✓ Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes. ________________________________________________________________________________________________________________________________________________ Notice of Change to Privacy Practices: ________________________________________________________________________________________________________________________________________________ ✓ Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION ________________________________________________________________________________________________________________________________________________ The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. ________________________________________________________________________________________________________________________________________________ WE WILL NOT USE OR DISCLOSE YOUR MEDICAL INFORMATION FOR ANY PURPOSE NOT LISTED BELOW, WITHOUT YOUR SPECIFIC WRITTEN AUTHORIZATION. ANY SPECIFIC WRITTEN AUTHORIZATION YOU PROVIDE MAY BE REVOKED AT ANY TIME BY WRITING TO US AT THE ADDRESS PROVIDED AT THE END OF THIS NOTICE. ________________________________________________________________________________________________________________________________________________ FOR TREATMENT: We may use your medical information to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, caregivers, or other people who are taking care of you. We may share medical information about you to other health care providers you designate to assist them in treating you. ________________________________________________________________________________________________________________________________________________ FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information. ________________________________________________________________________________________________________________________________________________ FOR REMINDERS: We may call, email, or send you mail regarding appointments, annual check-ups, and reminders.

YOUR INDIVIDUAL RIGHTS ________________________________________________________________________________________________________________________________________________ You have the right to: ________________________________________________________________________________________________________________________________________________ ✓ Look at or get copies of certain parts of your medical information. You must make your request in writing. ________________________________________________________________________________________________________________________________________________ ✓ Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions. ________________________________________________________________________________________________________________________________________________ ✓ Request that we communicate with you about your medical information by different means or at different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing. ________________________________________________________________________________________________________________________________________________ ✓ Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.

If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us at:

Denver Regenerative Medicine | 455 N Sherman St Ste 450, Denver, CO 80203

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Recurring CC Payment Authorization

You authorize regularly scheduled charges to your credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your credit card statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

I authorize Denver Regenerative Medicine to charge my credit card the following:

$193 - Testosterone replacement therapy (includes medicine, DOESN'T include labs) $208 - Testosterone replacement therapy (includes medicine AND labs)

Date of the month for the monthly fee processing

Billing Information

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Email:

Phone:

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Account/CC Number:

Expiration Date:

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I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Denver Regenerative Medicine in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.

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Sign-up Form

NOTICE OF PRIVACY PRACTICES

Social /Habits / Family / Education:

Payment Details

Contact Information

Mobile Phone:

Home Phone:

Mailing address, including zip code:

Email Address:

PATIENT INFORMATION

First Name

Middle Name

Last Name

Date of Birth (MM-DD-YYYY)

Age (Full Years

Sex Assigned at Birth

Marital Status:

Your Height (in.)

Your Present Weight (lb.)

Insurance Provider:

Insurance Id#:

Insurance Group#:

How Did You Hear About Us?

How did you hear about us? Please check applicable box below.

Dispensary (please list):

Other (please list):

EMERGENCY CONTACT

Local Friend or Relative:

Phone:

Relationship to you:

CERTIFICATION

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Please Read and Acknowledge the Privacy Statement Below

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Tells us about your lifestyle

Do you use: (please select all that apply)

Exercise/Hobbies/Recreation:

Have you been seen by a physician for the condition you are coming in for?

Are your medical records available if requested?

How do you rate your overall general health?

Do you have any drug allergies?

If selected "yes", please list:

Personal Health History: (please check ALL that apply)

If selected "Other", please specify:

Who is your current treating physician?

Please list ALL medications and dosages: (include supplements, prescription, and over the counter medications)

I certify that above statements are true and accurate to the best of my knowledge

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Recurring CC Payment Authorization

I authorize Denver Regenerative Medicine to charge my credit card the following:

Date of the month for the monthly fee processing

Billing Information

Billing Address

City

State

Zip

Email:

Phone:

Card Details

Cardholder Name:

Account/CC Number:

Expiration Date:

CVV

Zip Code:

I agree to the above statements and certify that information provided is correct

Your First nd Last Name

Today's Date (MM-DD-YYYY)