The U.S. Department of Health and Human Services has established the HIPAA Privacy Rule (45 C.F.R. Parts 160 and 164) to protect the privacy of individually identifiable health information and to establish standards for its use and disclosure. This rule requires covered healthcare providers to obtain patient acknowledgment of their Notice of Privacy Practices.

As our patient, we are committed to protecting the privacy of your Protected Health Information (PHI). We maintain reasonable administrative, physical, and technical safeguards to secure your health information. When necessary, we disclose only the minimum necessary information to individuals with a legitimate need-to-know for purposes of treatment, payment, or health care operations, in strict accordance with 45 C.F.R. § 164.502(b).

We support your full right of access to your personal medical records. In certain circumstances, we may share your PHI with third parties who provide services on our behalf (such as laboratories or reference services), pursuant to written Business Associate Agreements as required by HIPAA. These disclosures are made on a minimum-necessary basis and only for permitted purposes.

You have the right to consent to, restrict, or revoke consent for the use and disclosure of your PHI, subject to the limitations set forth in the HIPAA Privacy Rule. Any revocation must be submitted in writing and will not affect actions already taken in reliance on a prior consent. We reserve the right to decline to provide treatment if you refuse to consent to disclosures necessary for your care, as permitted by applicable law.

You have the right to review our full Notice of Privacy Practices prior to signing, to request restrictions on disclosures of your PHI, to request an accounting of disclosures, to request amendment of your records, and to file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights without retaliation. If you have questions or objections, please speak with our Privacy Officer before signing.

All employees, managers, and providers of Aquarius Medical Spa receive ongoing HIPAA privacy and security training and are bound by our internal Compliance Program. We are committed to the highest standards of privacy, security, and integrity in handling your health information.

This informed consent is provided in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable Arizona law to inform you of your rights and to document your voluntary agreement to the care and services described below.

Consent Related to Privacy Notice: I have had the opportunity to review the Practice HIPAA Notice of Privacy Practices as part of this registration process. I understand that the terms of the Notice may change and I may obtain revised notices by contacting the practice by phone or in writing. I understand I have the right to request an accounting of how my Protected Health Information (PHI) has been disclosed, and I have the right to request restrictions on such disclosures, though this practice is not required to agree to all requested restrictions. If the practice agrees to a restriction, it is bound by that agreement.

Consent for Care: I, with my electronic signature, authorize Aquarius Medical Spa, LLC, and its employees and providers acting under the direction of the supervising physician, to provide medical care to me, or to the patient for whom I am the legal guardian. This medical care may include, but is not limited to, preventative, diagnostic, therapeutic, rehabilitative, maintenance, and palliative care; counseling; assessment or review of physical or mental status; and the sale or dispensing of drugs, supplements, devices, or equipment in accordance with a prescription. This consent includes collaboration and consultation with other health care professionals involved in my care. I acknowledge that there are inherent risks associated with medical treatment, and I voluntarily assume those inherent risks. Nothing in this consent constitutes a waiver of any claim arising from the negligence, gross negligence, or willful misconduct of any provider.

Consent for IV Therapy: I hereby voluntarily consent to Aquarius Medical Spa performing intravenous (IV) vitamin and mineral therapy. I understand and acknowledge that: (a) intravenous nutrient therapy is not standard of care and is not widely approved or accepted for the treatment or prevention of disease; (b) its use in this context is considered experimental or investigational by a significant portion of the medical community; and (c) alternative treatment approaches exist, including prescription medications, over-the-counter drugs, and oral nutritional supplements, which have been discussed with me to my satisfaction.

I understand that the benefits of IV nutrient therapy may be greater when combined with a healthy lifestyle, and that an initial series of treatments may extend over several weeks or months. I may discontinue treatment at any time without incurring further charges after directing such discontinuation. As with any medical procedure, not all patients respond to this therapy.

I have been informed of possible risks and side effects including, but not limited to: discomfort or pain at the injection site, thrombophlebitis, fatigue, allergic or anaphylactic reaction, fluid overload or congestive heart failure, hypoglycemia, fever, and chills. I understand this therapy is generally contraindicated during pregnancy except in cases of severe or life-threatening illness. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I voluntarily consent to IV nutrient therapy with full understanding of the risks described. I acknowledge the inherent risks of this therapy but do not waive any rights I may have under applicable law.

Consent for Experimental Spa Therapy: I understand that certain spa therapies offered by Aquarius Medical Spa ("Aquarius Spa Therapy") may be experimental, investigational, or not yet approved by the U.S. Food and Drug Administration (FDA). I acknowledge that these therapies are not standard of care and may not have established clinical evidence of safety or efficacy for all applications. I understand that alternative conventional treatment options exist. Having been informed of the experimental nature of these therapies, I voluntarily consent to receive them. I acknowledge the inherent and unknown risks associated with experimental treatments and do not waive any rights I may have under applicable law, including any claims arising from negligence or misconduct.

Dispute Resolution — Agreement to Arbitrate: PLEASE READ THIS SECTION CAREFULLY. BY SIGNING BELOW, YOU ARE AGREEING TO RESOLVE DISPUTES THROUGH BINDING ARBITRATION AND WAIVING YOUR RIGHT TO A JURY TRIAL. I agree that any claim or dispute arising out of or related to the medical services, treatments, or care provided by Aquarius Medical Spa that cannot be resolved informally shall be submitted to final and binding arbitration administered by the American Arbitration Association under its Healthcare Due Process Protocol. This arbitration agreement is entered into voluntarily and independently of my consent to receive medical care. Nothing herein prevents either party from seeking emergency injunctive relief in a court of competent jurisdiction.

Consent for Release of Information and Assignment of Benefits: I authorize Aquarius Medical Spa to furnish necessary health information to identified insurance carrier(s) for billing and payment activities. I consent to assign benefits and direct all applicable insurance payments for services rendered directly to this practice. I further consent to the use of my information for operational purposes as described in the HIPAA Notice of Privacy Practices.

Financial Policy: I understand that I am financially responsible for all co-payments, deductibles, and any amounts not covered by my insurance plan, as determined by my insurance contract. Co-payments are due at the time of service. I acknowledge that it is my responsibility to verify my insurance coverage and applicable benefits prior to receiving services, as coverage varies by plan and employer group. Aquarius Medical Spa staff cannot guarantee coverage determinations. Services rendered outside the terms of my insurance contract may be my sole financial responsibility.

I have read and voluntarily agree to the Consents and Financial Policy stated above, have had the opportunity to ask questions, and accept the obligations described herein.