Service-Agreement

Renown Weight Loss Service Agreement

Client Name

First NameLast Name

Client DOB

Weight Loss Package

For Consultant to Fill In

Paid in Full

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Subtotal

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Discounts

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Total

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Payment Arrangements

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Down Payment

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Balance Remaining

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Follow Up Visits

For Consultant to Fill In

Medical Provider Visits

For Consultant to Fill In

Medication

For Consultant to Fill In

Lipotropic Injections

For Consultant to Fill In

KP 10 Injections

For Consultant to Fill In

THE FOLLOWING TERMS AND CONDITIONS SHALL APPLY to all Service Agreements between Renown Weight Loss (hereinafter , (hereinafter "Client" "Provider") and

Client Name

First NameLast Name

I, the undersigned client/patient, understand that I will not be prescribed any medication by the provider until the provider has reviewed my chart and approved my lab work results, EKG results, etc. I further understand that this could take up to 48 hours. I understand that if the provider does not approve my labs/EKG results, the provider may recommend a different program for which I medically qualify and that this is in the best interest of my health and wellness. I understand that I am not eligible for a refund for medical services rendered.

The goal of Renown Weight Loss is to provide excellent care to each client in a timely manner. If it is necessary to or cancel an appointment, clients are required to call or leave a message at least 24 hours before their appointment Notification allows the practice to better utilize appointments for other clients in need of prompt care.

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In the event a client arrives late as defined by "late arrival"* to their appointment, and cannot be seen by the provider same day, they will be rescheduled for a future clinic visit, if available.

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In the event a client has accrued three (3) documented "no shows"* or "same day cancellations"*, Renown Weight Loss the right to charge a fee of $25.

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Client shall be required to complete a Release of Liability form prior to removing any injections from the office that will administered by the Client.

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Client shall be required to complete an Automatic Debit Authorization should the Client choose to purchase their weight package via payment arrangements and agrees to allow set payments to be automatically debited by Provider on scheduled provided by Client.

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Any medications or injections removed from the Provider's office are NOT returnable or refundable.

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Packaged product(s) still in the original sealed container may be returned to Provider for in-center credit only.

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If Client chooses to purchase any Kisspeptin 10 (KP 10) product(s), Client acknowledges that KP 10 is neither returnable nor refundable

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If Client chooses to discontinue their program, any unused products and/or services must be used within one (1) year of last visit or they will expire and are null and void without refund.

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If Client chooses to discontinue their program, any unused products and/or services must be used within one (1) year of

Client's last visit or they will expire and are null and void without refund.

Client Signature

Date of Client Signature

Date

Consultant Signature

Date of Consultant Signature

Date

*"No Show" shall mean any client who fails to arrive for a scheduled appointment. "Same Day Cancellation" shall mean any client who cancels an appointment less than 24 hours before their scheduled appointment. "Late Arrival" shall mean any client who arrives at the clinic 15 minutes after the expected arrival time for the scheduled appointment.