WEIGHT LOSS PROGRAM CONSENT

Revised June 15, 2026

This Agreement outlines the terms and conditions of participation in the Weight Loss Program (the “Program”) and serves as an informed consent document.

For purposes of this Agreement, “Provider” refers to the treating medical provider contracted by Wellbeings Medical PAPC or Wellbeings Medical PLLC (collectively, the “Practice”). By enrolling in the Program, the participant (the “Member”) acknowledges, understands, and agrees to the following terms:

Active Membership

Monthly Fee: $299/month

The Active Membership is designed for Members who require ongoing medical supervision, frequent follow-up, and personalized support throughout their weight loss and metabolic health journey.

Active Membership includes:

• Two (2) video visits per month with a licensed medical provider

• Ongoing text and chat support with licensed medical provider 

• A personalized metabolic optimization plan, which may include:

  • Nutrition recommendations

  • Supplement recommendations

  • Movement and exercise guidance

  • Sleep and stress management support 

  • Mental health support 

• Optional laboratory ordering and review.

• Fee for comprehensive Hormone Optimization evaluation included, if clinically indicated or requested by the Member.

• Access to urgent-care type telemedicine visits as needed

Bridge Membership Program

Monthly Fee: $199/month

The Bridge Membership is intended for Members who have progressed beyond the need for biweekly Provider visits but would benefit from continued accountability and support while transitioning toward greater independence.

Eligibility for transition from the Active Membership to the Bridge Membership is based on the Member’s progress and the Provider’s determination that the Member is clinically ready for a lower level of support.

Bridge Membership includes:

• One (1) monthly video visit with a Health Coach.

• Ongoing lifestyle-change accountability and progress monitoring.

• Medication dosing adjustments and Provider visits on an as-needed basis, as determined by clinical necessity.

• If clinically indicated or requested by the Member, a new Hormone Optimization evaluation is charged at additional $150/month for new evaluation and an additional$49/month for hormone maintenance therapy

• Access to urgent-care type telemedicine visits as needed

Maintenance Membership Program

Monthly Fee: $99/month

Once a Member reaches their target weight or other pre-established treatment goal and has completed a follow-up discussion with their Provider and/or Health Coach, the Member may become eligible for the Maintenance Membership.

The Maintenance Membership is available only to Members who have successfully achieved their treatment goals and remain on a prescribed GLP-1 medication. Upon enrollment in the Maintenance Membership, the monthly fee will be reduced to $99 per month and will remain at that rate for as long as the Member remains enrolled and continues prescribed treatment.

Maintenance Membership includes:

• One (1) video visit with a Health Coach every six (6) months.

• Ongoing text and chat support with a licensed medical provider. 

• Access to urgent-care type telemedicine visits as needed

• The ability to self-schedule appointments with the Provider as needed with concerns pertinent to GLP-1 therapy or urgent care type matters, within reason (no more than once every 3 months unless emergency or urgent matter arises).

• If clinically indicated or requested by the Member, a new Hormone Optimization evaluation is charged at additional $150/month for new evaluation and $129/month for combined GLP-1 and hormone maintenance therapy

The Maintenance Membership is designed to provide continued support while requiring minimal Provider involvement due to the Member’s demonstrated progress and experience within the Program.

The Provider will not routinely initiate outreach to schedule appointments while the Member is enrolled in the Maintenance Membership. It is the Member’s responsibility to schedule any desired or recommended follow-up visits.

Pricing and Practice Fees

GLP-1 Peptides are provided to patients at the Practice's acquisition cost without additional markup. In addition to the cost of the peptide, a $100 Practice Fee per vial will be charged to cover the medical oversight, clinical support, and administrative services associated with treatment.

Because peptide availability, vendor sourcing, and market conditions may fluctuate, peptide pricing is subject to change without prior notice. The Practice will communicate any pricing changes before dispensing additional medication.

The $100 Practice Fee includes:

• $30 for clinical dosing review, prescription management, and administrative oversight;

• $30 for side effect monitoring, treatment support, and clinical guidance;

• $40 for concierge communication access, including ongoing messaging and patient support between visits.

The Member acknowledges that medication costs and Practice Fees are separate charges and understands that future pricing may vary based on product availability, vendor costs, and changes in supply.

Membership Billing and Cancellation

The Maintenance Membership fee is charged automatically on a recurring monthly basis until the Member elects to cancel the membership. To cancel, the Member must provide written notice to the Practice in accordance with the Program’s cancellation policy.

MINIMUM COMMITMENT: 

The Member is required to commit to a minimum of three months in the Program. Furthermore, if you choose to cancel the program after the initial 3 months, the rejoining fee is $299 and an additional two months minimum at $299/month or $99/month depending on which program you are joining (active or maintenance). 

PAYMENT OBLIGATIONS: 

Failure to make timely payments may result in a delay in care. If two consecutive payments are missed, the Member's membership will be canceled, and they will be unable to rejoin the Program in the future, including the $299 rejoin fee. 

NON-INSURANCE COVERAGE:

This practice does not accept or bill insurance for this treatment. The Member acknowledges that they are solely responsible for the cost of treatment.

REFUND POLICY:

Once treatment is initiated, refund requests based on scheduling conflicts, missed doses, or unsatisfactory results cannot be honored.

Cancellation & Termination Policy

A Member may cancel their participation in the Program at any time after three (3) months by providing written notice via email to the Provider. After 3 months, monthly memberships operate on a month-to-month basis and may be canceled by either party with written notice. Upon cancellation, the Provider will no longer be responsible for the Member’s care.

The membership fee is non-negotiable, non-refundable, non-transferable, and non-cancelable unless otherwise specified. The Provider reserves the right to cancel, suspend, or deny treatment if deemed medically necessary or if concerns arise regarding the Member’s health, inability to follow protocols, or unrealistic expectations. The Provider may terminate a membership at its discretion without issuing a refund.

FEE AND PAYMENTS: 

The recurring membership fee, as indicated above, shall be charged to Member’s credit card on file on a monthly basis. Membership fees will be charged directly to the Member's credit/debit account.

SERVICES: 

The Practice reserves the right to refuse or partially provide any treatment at its sole discretion. By entering into a membership agreement, the Member acknowledges that there is no entitlement or guarantee of receiving any specific treatment, and the Practice does not provide any warranty or guarantee regarding treatment outcomes. Results are not guaranteed or warranted in any way. The Practice retains the right to modify, add, or eliminate services or locations as needed.

MEMBER INFORMATION: 

The Member must disclose all relevant medical conditions that may impact or be affected by the services provided under this Agreement. It is the Member's responsibility to promptly notify the Practice of any changes in their information, including medical conditions, current address, billing details, or emergency contact.

NO GUARANTEE OR WARRANTY: 

By signing this waiver, the Member acknowledges that they have read and understood all the terms and conditions, including the benefits and limitations of the Practice  services. The Member certifies that they have disclosed all relevant medical conditions. The Member understands that there is no guarantee for any services provided by the Practice, and this membership agreement does not create an express or implied guarantee or warranty. The Member releases the Practice , its employees, and professionals from any liability arising from any treatment performed or not performed.

ENTIRE AGREEMENT: 

This Agreement represents the complete terms and conditions of the membership. Any modifications to this Agreement must be made in writing and signed by both the Practice  and the Member.

By signing below, I confirm that I have read and understood this Membership Agreement, including the attached terms and conditions, and I agree to be bound by all its provisions. I hereby authorize the Practice  to charge my provided credit card in accordance with the terms outlined in this membership agreement, either as a single charge or on a recurring monthly basis. If a monthly membership is selected, I acknowledge that my credit card will be charged on the membership effective date and subsequently on the same day of each month thereafter. I acknowledge that this program is not covered by insurance and that I do not expect any insurance reimbursement. I understand that there are no refunds for any reason.

CONSENT FOR TREATMENT IN WEIGHT LOSS + METABOLIC HEALTH PROGRAM 

This document serves as an informed consent agreement between the patient (referred to as the "Member") and Wellbeing Medical Physician Assistant PC or or Wellbeings Medical PLLC (referred to as the “Practice”) regarding the provision of medical treatment and healthcare services by the treating medical provider hired by the Practice {referred to as “Provider”). By requesting and receiving treatment from the Practice the Member acknowledges and agrees to the following:

Treatment Description: 

The Member acknowledges that they have requested medical treatment and other healthcare services from licensed and certified providers through the Practice's telehealth platform. The specific services may include health evaluation and management, health assessments, primary care services, and laboratory panel services. The Member consents to receive these services as deemed necessary and appropriate by the providers.

Right to Decline Treatment: 

The Member understands that they have the right to decline treatment and services at any time.

Primary Care Provider Follow-up:

 If the Provider is not the Member's primary care provider, it is the Member's sole responsibility to follow up with their primary care provider regarding any medical conditions or treatments discussed during the assessment and/or treatment provided by the Provider.

CONSENT FOR TREATMENT WITH GLP-1, GIP, AND RELATED PEPTIDE THERAPIES

I have reviewed and understand the information provided regarding semaglutide, tirzepatide, retatrutide, and cagrilintide, including their brand-name equivalents, compounded formulations, and/or formulations combined with other ingredients such as methylated vitamin B12 or BPC-157, which may be utilized as part of the weight loss and metabolic optimization program offered by the Practice.

Medication Description

Semaglutide

Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist marketed under brand names including Ozempic® and Wegovy®. Semaglutide works by mimicking the naturally occurring GLP-1 hormone, which helps regulate appetite, slow gastric emptying, increase insulin secretion when blood sugar levels are elevated, and decrease glucagon secretion. These actions can reduce hunger, increase satiety, improve glycemic control, and promote weight loss.

Wegovy® is FDA-approved for chronic weight management in adults with obesity or overweight individuals who have at least one weight-related medical condition. Ozempic® is FDA-approved for the treatment of type 2 diabetes and to reduce certain cardiovascular risks in appropriate patients.

Tirzepatide

Tirzepatide is a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist, commonly referred to as a "twincretin." It is marketed under the brand names Mounjaro® and Zepbound®.

Mounjaro® is FDA-approved for the treatment of type 2 diabetes. Zepbound® is FDA-approved for chronic weight management in adults with obesity or overweight individuals who have at least one weight-related medical condition. Tirzepatide works through activation of both GLP-1 and GIP receptors, resulting in appetite suppression, delayed gastric emptying, improved insulin sensitivity, enhanced glucose regulation, and significant weight reduction.

Retatrutide

Retatrutide is an investigational medication currently being studied for chronic weight management and metabolic disease. Retatrutide acts as a triple hormone receptor agonist, targeting GLP-1, GIP, and glucagon receptors. Clinical trials have demonstrated substantial weight-loss potential; however, retatrutide has not received FDA approval for any indication as of the date of this consent.

The safety profile of retatrutide continues to be evaluated in ongoing clinical studies. Known and potential side effects may be similar to those observed with GLP-1 receptor agonists and other incretin-based therapies, including gastrointestinal side effects and other risks described below.

Cagrilintide

Cagrilintide is a long-acting amylin analog being studied for the treatment of obesity and metabolic disease. It is designed to mimic the effects of amylin, a naturally occurring hormone involved in appetite regulation, satiety, and gastric emptying.

Cagrilintide has demonstrated promising weight-loss results in clinical studies, particularly when used in combination with semaglutide. However, cagrilintide has not received FDA approval for any indication as of the date of this consent. The safety and efficacy profile continues to be evaluated through ongoing clinical trials.

Compounded Medications

I understand that some medications prescribed through the Practice may be compounded medications obtained from licensed compounding pharmacies. Compounded medications are not FDA-approved and may differ from commercially available brand-name products manufactured by Novo Nordisk®, Eli Lilly®, or other pharmaceutical manufacturers.

Compounding pharmacies utilize pharmaceutical ingredients sourced from FDA-registered suppliers; however, compounded medications themselves are not reviewed, approved, tested, or monitored by the FDA for safety, efficacy, or quality in the same manner as commercially manufactured products.

I acknowledge that compounded medications may have differences in formulation, concentration, inactive ingredients, or route of administration compared to commercially available medications.

Compounded and Research-Use Peptide Products

I understand that medications prescribed through the Practice may be sourced from licensed compounding pharmacies when available and clinically appropriate. Certain peptides may also be available through research or compounding laboratory formulations when commercially compounded products are unavailable, limited in supply, or otherwise deemed appropriate by my Provider.

I understand that compounding pharmacy formulations are preferred whenever available and clinically appropriate. However, due to market availability, supply chain limitations, regulatory changes, or other factors, the Practice may consider alternative formulations for select peptides.

If treatment with a compounding laboratory or other non-traditional peptide formulation is being considered, my Provider will discuss this recommendation with me during a medical visit. Prior to initiating such treatment, I will be provided with additional information regarding the potential risks, benefits, alternatives, and limitations of the proposed therapy. I understand that a separate written informed consent may be required and must be signed before treatment can begin.

I acknowledge that I will have the opportunity to ask questions regarding any proposed medication or formulation and that I may decline treatment if I do not wish to proceed.

Treatment Alternatives

I understand that alternatives to treatment include, but are not limited to:

• Lifestyle modification through diet and exercise alone

• Nutritional counseling

• Behavioral health interventions

• Other FDA-approved weight-loss medications

• Bariatric or metabolic surgery

• Electing to receive no treatment

• Potential Risks and Side Effects

I understand that semaglutide, tirzepatide, retatrutide, cagrilintide, and related therapies may be associated with risks and adverse effects, including but not limited to

• Nausea

• Vomiting

• Diarrhea

• Constipation

• Abdominal pain

• Indigestion or reflux

• Decreased appetite

• Fatigue

• Headache

• Dizziness

• Injection site reactions

• Dehydration

• Acute pancreatitis

• Gallstones or gallbladder disease

• Acute kidney injury

• Gastroparesis or delayed gastric emptying

• Intestinal obstruction or ileus

• Hypoglycemia, particularly when combined with other diabetes medications

• Increased heart rate

• Worsening diabetic retinopathy in susceptible individuals

• Allergic or hypersensitivity reactions

• Suicidal thoughts or mood changes

• Potential fetal harm if used during pregnancy

Animal studies involving certain GLP-1 receptor agonists demonstrated an increased risk of thyroid C-cell tumors. Although this risk has not been established in humans, these medications should generally be avoided in patients with a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2).

Because retatrutide and cagrilintide remain investigational therapies, additional risks and side effects may be unknown at this time.

Increased Fertility and Oral Contraceptive Considerations

I understand that significant weight loss and improved metabolic health may improve fertility and restore ovulation, particularly in individuals with insulin resistance or polycystic ovary syndrome (PCOS).

I further understand that medications which delay gastric emptying, including semaglutide, tirzepatide, retatrutide, and cagrilintide, may decrease the absorption and effectiveness of oral contraceptive medications. I agree to discuss appropriate contraception options with my healthcare provider and understand that additional or alternative contraceptive methods may be recommended.

Muscle Mass Preservation

I understand that weight loss may result in the loss of both fat mass and lean muscle mass. To help preserve muscle mass and optimize metabolic health, I agree to:

• Meet daily protein intake recommendations provided by the Practice.

• Participate in regular resistance or strength-training exercise.

• Follow nutritional and exercise recommendations provided by my Provider and/or Health Coach.

I understand that failure to consume adequate protein or engage in resistance training may increase the risk of excessive muscle loss during treatment.

Patient Acknowledgments

By signing this consent, I certify that:

Age and Capacity

• I am at least 18 years of age and capable of understanding the information provided regarding these medications and treatment options.

Medical Disclosure

• I have disclosed all relevant medical conditions, medications, supplements, allergies, and changes in my health status to my Provider.

Voluntary Participation

• I voluntarily choose to proceed with treatment utilizing semaglutide, tirzepatide, retatrutide, cagrilintide, and/or related compounded peptide therapies as determined appropriate by my Provider.

Understanding of Risks and Benefits

• I understand the potential benefits, risks, side effects, limitations, and uncertainties associated with treatment.

Opportunity for Questions

• I have had the opportunity to ask questions and have received satisfactory answers in language that I understand.

Reporting Adverse Events

• I agree to promptly notify the Practice of any adverse reactions, complications, side effects, pregnancy, significant health changes, or concerns that arise during treatment.

No Guarantee

• I understand that no guarantee has been made regarding specific outcomes, weight loss results, health improvements, or treatment success.

Consent

Based upon the foregoing information, I knowingly and voluntarily consent to treatment with semaglutide, tirzepatide, retatrutide, cagrilintide, and/or related compounded peptide therapies as recommended by my Provider. I acknowledge that I have read and understood this consent, have had the opportunity to ask questions, and agree to comply with treatment recommendations and follow-up requirements throughout my participation in the Program.