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I do hereby consent to any medical care which is deemed advisable or necessary by my healthcare provider and grant authority to Badia Hand to Shoulder Center, to administer and perform all examinations, treatments, diagnostic procedures and surgeries needed now or in the future. I guarantee payment for all services rendered. All medical benefits including major medical benefits, private insurance, and any other health plan, are assigned to Badia Hand to Shoulder Center. The signature below confirms all of the information provided herein is true and accurate. Photocopy of this consent is to be considered as valid as the original.

Acknowledgment of Privacy Practices

I hereby acknowledge that I have received a copy of OrthoNOW Notice of Privacy Practices as required by federal law.

Financial Responsibility & Financial Policy:

I hereby acknowledge that I have received a copy of OrthoNOW Financial Policy and have read the Financial Responsibility Statement. By signing below, you agree to all of the terms and conditions contained herein the OrthoNOW Financial Policy and the Financia I Responsibility Statement will be in full force and effect.

I hereby acknowledge that OrthoNOW may be out of network with my insurance plan and that charges may apply to my out of network benefits. I understand that I will be fully responsible for any outstanding balance on my account.

Patient Consent for use and disclosure of Protected Health Information:

I authorize the office of OrthoNOW to disclose protected health information to the following:

Female Patients - Radiologic Consent

We will be performing a radiological examination using digital x-rays. The radiation used may be harmful to an unborn child/developing fetus, especially during the first trimester. In order to help prevent the accidental irradiation of an unrecognized pregnancy and in accordance with the National Standards, we require the following information o female patients of child bearing age.

I have been fully informed of the risk involved in radiation of a first trimester pregnancy and assume the responsibility for any consequences from the procedures that I am about to have. I understand that I will not hold OrthoNOW. LLC and Badia Hand to Shoulder, LLC responsible for any potential halm to myself or my unborn child. By signing below, 1 consent to the necessary X-ray procedures.

I __________________ (Subject/Parent/Legal Representative) hereby authorize OrthoNOW, its staff agents and employees to take and produce photographs, video and/or audio recordings and to use such photographs, video and/or audio recordings for purposes that include, but are not limited to, publication. both in print and online at OrthoNOW's sole discretion.

I ____________________ (Subject/Parent/Legal Representative) consent and authorize OrthoNOW, to take and reproduce photographs, video, and/or audio recordings of ______________________ (state name of subject) for the authorized subject'sor parent/legal representative's personal use. OrthoNOW. reserves the right to limit or prohibit the taking and/or reproduction of photographs, video and/or audio recordings of.

I hereby release OrthoNOW, its staff, agents, officers, directors, and employees from any and all liability and claims related to the taking, reproduction, and/or use of such photographs, video and/or audio recordings and the release of information concerning (the authorized subject) acquired by the staff, agents. officers, directors, and employees pursuant to this authorization. It is expressly understood that this authorization and consent includes permission for the release of the authorized subject's information regarding the subject's name, photograph, medical image studies. video and/or audio recording for the purpose of publication, both in print and online.

Authorized subject/Parent/Legal Guardian: I understand that I may revoke this authorization at any time in writing to OrthoNOW. This authorization is in effect in perpetuity from the date of signature.