This CLIENT SERVICES AGREEMENT (this “Agreement”), dated by and between (“Client”) and [Dr. Takashi Nakamura] , a Missouri [Board Certified Physician] of (“MalCole Drip and Beauty Bar LLC”).

Service Provider and Client desire to enter into this Agreement to set forth the terms and conditions on which Service Provider will provide services to Client from time-to-time. Therefore, in consideration of the mutual promises contained herein, the parties hereto agree as follows:

1. SERVICES. MalCole Drip and Beauty Bar, LLC ( MalCole ) may administer intravenous hydration therapy, intramuscular injection therapy, or other therapies MalCole offers in the future.SERVICES.

MalCole Drip and Beauty Bar, LLC (MalCole) may administer intravenous hydration therapy, intramuscular injection therapy, or other therapies
MalCole offers in the future.

2. MEDICAL CONDITIONS. Medical Condition. Client understands, represents, and warrants that Client is not pregnant and does not have heart, kidney, lung, liver, or any neurological problem(s). Client understands and agrees that if Client has any of the aforementioned conditions, Service Provider will be unable to provide services to Client. Client understands, represents, and warrants that Client has spoken with his or her primary care physician and received approval to obtain the Services.

3. RIGHT TO REFUSE SERVICE. MalCole may refuse care or services based onMalCole’s provider’s professional opinions. MalColeproviders also have the right (but not the obligation) to call 911 or refer you for further medical attention.

4. RESULTS. Each individual is different. You acknowledge there is NO GUARANTEE as to results from the servicesMalColeprovides, and that the services may not provide the result you seek and expect.

5. ASSUMPTION OF RISK. You understand and agree that intravenous access or intramuscular injections come withpotential risks. These risks include but are not limited to: allergic reaction, infection,discomfort, bruising, pain, inflammation, phlebitis, metabolic disturbances, hypothermia, embolism, cardiac arrest, and even death. You knowingly, voluntarily, and fully assume the risks associated with obtaining services from MalCole Drip and Beauty Bar.

6. SCHEDULING AND CANCELLATION. Your time is valuable.  We try to stay on schedule, so you and other patients don’t have to wait. If you are more than 10 minutes late for your appointment, we may reschedule you. Because MalCole reserves any requested and agreed upon time and date for you to receive services, MalCole asks for a deposit when making an appointment.  If you cancel an appointment with more than 24 hours’ notice, you will receive a full refund of the deposit.  If you cancel an appointment with notice of 24 hours or less, your deposit is forfeit and you will not receive a refund.

7. HIPPA PRIVACY POLICY. You acknowledge you have been given or offered and understand, the notice of our privacy practices. You understand the terms of the privacy notice maychange and you may obtain the revised notices by contacting us by phone or in writing. You understand you have the right to request how your protected health information (PHI) has been disclosed. Youunderstand you have the right to restrict how the information is disclosed, but we are not required to agree to your restrictions. If we do agree to your restrictions on PHI use, we are bound by that agreement.

8. CONSENT FOR CARE. You, with your signature, authorize this practice, and any staff member working under the direction of the medical provider, to provide medical care for me, or to this patient for which you are the legal guardian. This medical care may include services and supplies related to your health (or the identified person) and may include (but is not limited to)intravenous hydration services and intramuscular injection services. This consent includes contact and discussion with other health care professionals for care and treatment.

9. DISPUTE RESOLUTION. You agree to provide MalCole with written notice of any dispute, claim, or controversy (Claim), of any sort or nature, arising out of the services MalCole provides, or with MalCole’s staff, within 6 months after any such claim, dispute or controvery arises. Any failure to strictly follow the procedures stated in this section shall constitute an unconditional WAIVER of any Claim that may exist or you have against MalCole or anyone affiliated with MalCole. You agree to pay MalCole’s reasonable attorneys’ fees for defending a lawsuit in which the dispute resolution procedure stated herein has not been strictly followed.

10. RELEASE AND INDEMNITY.  YOU RELEASE MALCOLE, ITS OWNERS, MEMBERS, OFFICERS, MANAGERS, AGENTS, CONTRACTORS, EMPLOYEES, LICENSEES, AND INVITEES (MALCOLE GROUP) FROM ANY AND ALL LIABILITY FOR, AND AGREES TO INDEMNIFY AND HOLD SERVICE PROVIDER GROUP HARMLESS FROM AND AGAINST, ANY AND ALL LOSSES, CLAIMS, EXPENSES, COSTS, AND DAMAGES, INCLUDING BUT NOT LIMITED TO REASONABLE ATTORNEYS’ FEES, COSTS, OR EXPENSES, WHICH ARE CLAIMED OF OR SUSTAINED, SUFFERED, PAID, OR INCURRED BY MALCOLE GROUP, IRRESPECTIVE OF MALCOLE GROUP’S NEGLIGENCE (EXCEPT GROSS NEGLIGENCE), FOR REASON OF OR IN CONNECTION WITH (A) YOUR DECISION TO REQUEST OR RECEIVE THE SERVICES, (B) MALCOLE’S PERFORMANCE OF THE SERVICES, OR (C) YOUR BREACH OF OR FAILURE TO FULFILL ANY PROVISION OF THIS AGREEMENT, WHETHER SUCH BREACH IS MATERIAL OR NOT. YOU ASSUME FULL LIABILITY FOR ANY ADVERSE EFFECTS THAT MAY RESULT FROM THE ADMINISTRATION OF THE SERVICES AND WAIVE ANY CLAIM IN LAW OR EQUITY FOR REDRESS OF ANY GRIEVANCE THAT YOU MAY HAVE CONCERNING OR RESULTING FROM THIS PROCEDURE.

11. LIMITATION OF LIABILITY. NEITHER MALCOLE NOR ANY OF ITS AFFILIATES, OWNERS, MEMBERS, MANAGERS, OFFICERS, EMPLOYEES, AGENTS, REPRESENTATIVES, OR CONTRACTORS (EACH A “RELATED PARTY” AND, COLLECTIVELY, THE “RELATED PARTIES”) SHALL BELIABLE FOR ANY LOSS, LIABILITY, DAMAGE, OR EXPENSE ARISING OUT OF OR IN CONNECTION WITH THE SERVICES, UNLESS SUCH LOSS, LIABILITY, DAMAGE, OR EXPENSE SHALL BE PROVEN TO RESULT DIRECTLY FROM THE WILLFUL MISCONDUCT OR GROSS NEGLIGENCE OF SUCH PERSON. NONE OF THE RELATED PARTIES SHALL BE LIABLE FOR ANY INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, OR PUNITIVE DAMAGES (EVEN IF SERVICE PROVIDER HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES). IN NO EVENT WILL THE AGGREGATE LIABILITY OF MALCOLE, ITS OWNERS, MEMBERS, MANAGERS, OFFICERS, EMPLOYEES, AGENTS, AND CONTRACTORS FOR ANY AND ALL OF CLIENT’S CLAIMS, OR ANY THIRD PARTY CLAIMS, AGAINST MALCOLE AND/OR ITS OWNERS, MEMBERS, MANAGERS, OFFICERS, EMPLOYEES, AGENTS, AND CONTRACTORS, ARISING OUT OF OR RELATED TO, DIRECTLY OR INDIRECTLY, THE PERFORMANCE OR NONPERFORMANCE OF ANY SERVICES OR BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF MALCOLE, EXCEED THE GREATER OF (A) THE AMOUNT OF FIVE HUNDRED DOLLARS ($500.00) OR (B) THE FEES ACTUALLY PAID TO SERVICE PROVIDER HEREUNDER. YOU AGREE THAT THIS LIMITATION OF LIABILITY REPRESENTS A REASONABLE ALLOCATION OF RISK. THIS ALLOCATION OF RISK IS A FUNDAMENTAL ELEMENT OF THIS AGREEMENT.

12. GENERAL TERMS. In this Agreement, when “you” is utilized, it means the patient who signs this Agreement. This Agreement, the HIPAA Notice of Privacy Practices, the MalCole’s website terms of use, and any informed consent form between the parties is the entire agreement between the parties. MalCole’s failure to enforce or demand strict compliance of any right or provision in this Agreement will not constitute a waiver of such or any other provision. If any provision of this Agreement, or any portion thereof, is held to be invalid and unenforceable, the remainder of this Agreement shall remain in full force and effect. The governing law of this Agreement is the law of the state of Missouri without giving effect to any choice or conflict of law provision or rule. Any legal suit, action or proceeding arising out of or relating to this Agreement shall be instituted in the courts in St. Louis City County or St. Louis County, Missouri.

Service Provider:

[Dr. Takashi Nakamura]

Jessica Malone, RN

Title: Authorized Signatory

FINANCIAL POLICY

1. You are responsible for paying for the services we provide. We are a cash-only clinic. This means you have to pay in full when you receive the service. We accept cash, check, and some credit cards. You can file a claim with your insurance or with your employer’s health savings account program, unless you have Medicare or Medicaid. We make NO GUARANTEES that your insurance or employer covers the services we provide.

2. Prompt Pay Discount. MalCole may provide a prompt payment discount. If you don’t pay in full at time of service, you agree to pay the full-service price without the prompt payment discount. The prompt payment discount may range from $30 to $50 for each service, or more, in MalCole’s sole discretion.

3. Travel Fee. MalCole may charge a travel for services under a certain dollar threshold. The threshold is determined by MalCole, in its sole discretion.

4. Concierge Service Policy. You must present identification upon MalCole’s arrival to provide services. You agree to pay the remaining balance owed directly after services are provided. If you are not at the agreed upon location for the appointment when MalCole arrives, you will be charged full price for the scheduled services, and you agree not to book appointments for any services until the balance is paid in full.

5. Refunds. There are no refunds issued after services are provided. In our sole discretion, we may allow certain payment arrangements in extreme cases of medical need and the patient’s lack of financial ability to pay in full at the time of service. However, you must pay all balances within the timeframe determined by MalCole. We will charge a 10% late fee as well as 15% interest (calculated annually) when you don’t make payments as scheduled. If you don’t make your scheduled payments, we may turn your account over to a collection agency. If your account requires work to collect the balance, such as help from an attorney or a collection agency, you agree to pay all costs to collect the debt. This includes, but isn’t limited to, interest, attorney’s fees, court costs, and collection fees. You are obligated to pay the collection fees at the time we assign the debt to a third-party debt collection agency. All payments will first be credited to collection costs, attorney fees, and accrued interest. By signing this agreement, you acknowledge and understand this financial policy and agree to it. You understand you are legally bound to all financial obligations regardless of marital status, insurance coverage, or lack of insurance coverage.