PATIENT INFORMATION

Lammons Healthcare & Associates, PLLC / X Equities LLC DBA X Wellness / WoundX

I hereby authorize Lammons Healthcare & Associates, PLLC and X Equities LLC, DBA X Wellness / WoundX, and its licensed providers to evaluate, examine, and provide elective medical, regenerative, aesthetic, wellness, and cellular-based treatments.

All services are elective, provider-directed, and performed in accordance with applicable Texas and federal law.

I understand that care provided may involve the use of medications, compounded therapies, peptides, biologics, injectable substances, IV therapies, medical devices, and/or procedures, selected based on provider judgment following medical evaluation.

I understand that certain therapies offered may be investigational, experimental, or not approved by the U.S. Food and Drug Administration (FDA).

I acknowledge that:

• These therapies are not FDA-approved to diagnose, treat, cure, or prevent disease unless explicitly stated
• Some therapies may be classified as human cells, tissues, and cellular or tissue-based products (HCT/Ps)
• Therapies may fall under Section 361 or Section 351 regulatory pathways
• Treatments provided may not meet criteria for full FDA approval
• These services may not be considered standard medical care

All services are provider-directed, elective in nature, and performed within the scope of applicable Texas and federal law.

Scope of Services

This authorization applies to all services offered by the practice, including but not limited to:

Includes but is not limited to:

• Wound care and tissue repair
• PRP and autologous biologics
• Peptides and metabolic therapies
• Aesthetic procedures
• Hair restoration
• IV therapies (hydration, vitamins, NAD+)
• Joint and musculoskeletal injections
• Cellular therapies including, but not limited to:
• Stem cell–related or derived products
• Autologous or allogeneic biologics
• Exosomes / extracellular vesicles

CELLULAR / STEM CELL THERAPY DISCLOSURE

I understand that cellular therapies:

• May be investigational and not FDA-approved
• Are not standard of care
• Have uncertain long-term safety and efficacy
• Do not guarantee outcomes

ROUTE OF ADMINISTRATION DISCLOSURE

• Local injection
• Topical/procedural application
• Intravenous (IV) infusion

IV therapy carries increased systemic risk and regulatory scrutiny

FINAL ACKNOWLEDGMENT

By signing below, I acknowledge that:

• I understand the experimental and investigational nature of certain therapies
• I accept all known and unknown risks
• I have had the opportunity to consult with a healthcare provider
• I voluntarily choose to proceed

I understand that peptide therapy involves the use of specific amino-acid sequences designed to support normal physiological signaling and regulatory processes within the body. Peptides may be utilized as part of a wellness, recovery, metabolic, or regenerative care plan when deemed clinically appropriate by a licensed provider.

I acknowledge and understand that:

• Peptides are not steroids, hormones, or controlled substances.
• Peptide therapy may involve off-label use, which is a common and accepted medical practice.
• Peptides are not FDA-approved to diagnose, treat, cure, or prevent disease.
• No specific outcomes or guarantees have been made.
• Individual responses to peptide therapy may vary.
• Product Labeling Disclosure & Patient Acknowledgment

I understand that certain peptide products provided through compounding channels or external suppliers may include information and labeling such as:

• “Not for human consumption”
• “For research use only”
• “Not FDA approved”

I acknowledge that such direction and labeling may reflect supplier classification, packaging standards, or regulatory distribution language and may not reflect individualized provider-directed clinical protocols.

I acknowledge that I have reviewed and understand these labeling statements, and I still voluntarily choose to proceed with peptide therapy under my provider’s direction.

Voluntary Election, Assumption of Risk & Financial Responsibility

By choosing to proceed with peptide therapy, I confirm that I am voluntarily electing to receive peptide-based treatment as part of an elective wellness or regenerative program. I acknowledge that all therapies may carry risk, including side effects, lack of improvement, or unexpected outcomes, and I accept responsibility for these risks.

I understand that peptide therapy is an elective, cash-pay service and I am financially responsible for all charges. I further understand that no refunds will be issued once a peptide product has been prepared, dispensed, opened, or administered, regardless of outcome.

I understand that peptide therapy is provider-directed, may be modified, paused, or discontinued at any time based on clinical judgment, and requires adherence to proper administration, storage, and handling instructions.

I confirm that I have had the opportunity to ask questions regarding peptide therapy (including risks, benefits, alternatives, and product labeling), and that my questions have been answered to my satisfaction.

Limited Release Related to Product Labeling

I acknowledge that I have been informed certain peptide products may include labeling such as “not for human consumption” or “for research use only.” By signing this consent, I voluntarily elect to proceed with treatment and agree that I will not hold Lammons Healthcare & Associates, PLLC / X Equities, LLC, DBA X Wellness, its providers, or staff responsible for claims arising solely from supplier labeling language, provided that my care is administered under provider supervision and in accordance with my individualized treatment plan and applicable standards of care.

Pharmacy Dispensing & Handling
I acknowledge that all medications used in regenerative and peptide-based care:
Are prescribed by a licensed healthcare provider
Are dispensed by a state-licensed U.S. compounding pharmacy or FDA-registered outsourcing facility
May be shipped to the clinic or directly to the patient in compliance with state and federal regulations.

Lammons Healthcare & Associates, PLLC / X Equities, LLC — DBA X Wellness (Applies to All Regenerative, Aesthetic, Wellness & Cash-Pay Services)

1. Elective, Cash-Pay Services

I understand that all services provided by Lammons Healthcare & Associates, PLLC DBA WoundX / X Equities, LLC, DBA X Wellness are elective, cash-pay services.

Includes but is not limited to:

• Wound care and tissue repair
• PRP and autologous biologics
• Peptides and metabolic therapies
• Aesthetic procedures
• Hair restoration
• IV therapies (hydration, vitamins, NAD+)
• Joint and musculoskeletal injections
• Cellular therapies including, but not limited to:
• Stem cell–related or derived products
• Autologous or allogeneic biologics
• Exosomes / extracellular vesicles

I understand these services are not billed to insurance, and the practice does not submit claims on my behalf

2. Payment Responsibility

I agree that:

• Payment is due in full at the time of service, unless otherwise arranged in writing.
• I am fully responsible for all fees associated with my elective treatments.
• Once treatment has been rendered, products prepared, or materials opened, all fees are non-refundable.
• Any outstanding balances must be paid promptly to maintain access to future services

3. No Insurance Involvement

I acknowledge that:

• Insurance is not accepted for any services provided.
• I am not assigning insurance benefits to Lammons Healthcare & Associates, PLLC / X Equities, LLC, DBA X Wellness.
• Whether I choose to self-submit information to my insurance is voluntary and not guaranteed to result in reimbursement.
• My financial responsibility exists regardless of insurance coverage or denial.

4. Returned Payments & Past-Due Balances

I understand that:

• Returned payments or chargebacks may incur administrative fees.
• Past-due balances may affect access to future appointments or treatments.
• Accounts may be sent to a third-party billing service or collection process if not resolved in a timely manner.

5. Communication & Documentation Authorization

I authorize the practice to use secure digital systems, including recording, transcription, and electronic documentation tools, for the purpose of:

• Creating accurate medical records
• Treatment planning and continuity of care
• Internal quality assurance

I understand these tools comply with HIPAA, and no clinical recording or photograph will be used publicly or for marketing without my written authorization.

6. Acknowledgment of Financial Responsibility

By signing this agreement, I acknowledge and agree that:

• I have read and fully understand this Financial Policy.
• I understand that I am fully financially responsible for all elective services I choose to receive.
• I agree to pay all charges in accordance with this policy.
• I understand that failure to pay may result in the account being placed on hold or submitted for collection.
• I understand that services rendered are non-refundable, and payment is required whether treatments meet subjective expectations or not.

I hereby consent to allow Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness., its agents, representatives, employees, successors, or assign to photograph, and/or videotape. I further grant to Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness the right and permission to copyright, reproduce, broadcast, telecast, and/or publish the photograph(s), film, videotape, recordings, endorsement, or copy in which I may include in whole or part or composite form for utilization in diagnostics, documentation, treatment, and/or teaching or demonstration purposes, or art purposes, trade, website use, advertising, and all advertising media, or for any lawful reproduction purpose.

I understand that these images will be stored in a secure manner to protect them from unintended use by unauthorized parties. I understand and agree that these images/recordings may include inferring information regarding medical conditions and/or treatment at the Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness locations and affiliated entities.

I understand and agree that I have the right to rescind this agreement and Lammons Healthcare & Associates, PLLC., will not make any additional media placement of my images or recordings. I also understand that Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness, will not withdraw any media where my images or recordings have already been placed. To rescind approval, I must submit a request in writing to Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness.

Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness (including WoundX) is committed to enhancing the accuracy, efficiency, and quality of medical documentation. As part of this process, recording devices may be used to capture verbal dictation of SOAP (Subjective, Objective, Assessment, and Plan) notes, which are then transcribed and entered into the Electronic Medical Record (EMR). This method improves workflow efficiency, ensures accurate and timely documentation, and enhances overall patient care.

By signing below, you acknowledge and agree to the following:

Authorization for Recording: You authorize Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness and its designated providers to use audio recording devices to document SOAP notes for medical purposes. These recordings are intended solely for clinical documentation and will not be shared, distributed, or used for any purpose beyond patient care and recordkeeping.

Confidentiality & HIPAA Compliance: Lammons Healthcare & Associates, PLLC. & X Equities LLC., DBA X Wellness adheres to all HIPAA regulations and confidentiality standards to protect patient information. Recordings will be securely stored and deleted upon successful transcription into the EMR.

Efficiency & Accuracy: The use of recording technology streamlines documentation, reducing administrative burdens and ensuring the correct and complete logging of medical notes, leading to improved patient outcomes.

Limited Use & Access: Access to recorded dictations will be restricted to authorized medical personnel responsible for transcription and documentation. No recordings will be used for training, research, or any other non-clinical purpose without prior written consent.

Right to Revoke: You have the right to withdraw this authorization at any time by providing written notice to Lammons Healthcare & Associates, PLLC. However, withdrawal will not apply to recordings already transcribed and incorporated into the medical record.

Acknowledgment of Consent: You understand that this authorization is voluntary and that declining or revoking consent may require alternative documentation methods.

By signing below, you acknowledge that you have read and understand this authorization and consent to the use of recording devices for SOAP note documentation.

I understand that I may revoke this consent at any time in writing, except to the extent that action has already been taken based on this authorization

I understand that I have the right to request a copy of my medical records maintained by Lammons Healthcare & Associates, PLLC / X Equities, LLC, DBA X Wellness in accordance with HIPAA and applicable state privacy laws.

If I choose to request a printed copy of my records, I acknowledge and agree to the following:

1. Written Request Required
I must submit a written request identifying the specific records or date range I am requesting.
2. Identity Verification
I understand that valid government-issued identification may be required before records can be released.
Records will only be released to:

• Me (the patient),
• A legally authorized representative,
• Or a healthcare provider with appropriate written authorization.

3. Printing & Administrative Fees
I acknowledge that printed medical records may incur reasonable fees, including but not limited to:

• $25 per request
• Optional mailing or secure delivery fees
• I understand that these charges must be paid in full before records are released.

4. Processing Time
I understand that medical record requests may take up to 15 business days to process, depending on the volume and nature of the request.
5. Electronic Copies
I may request my records electronically at no charge when feasible, and I acknowledge that printing or physical media may still incur fees.
6. Sensitive or Restricted Information
Certain information (such as mental health notes or third-party data) may be released only as allowed by law.

By signing the full consent document, I acknowledge that I understand my rights regarding medical record requests and agree to the associated requirements and fees should I request printed copies.