X

Hormone Replacement Therapy (HRT) Protocol Agreement

Health and wellness, along with medical stability of our patients, is the priority of Ikigai Energy, LLC.

1) Protocols and recommended treatment will be based on the discretion of the practitioner performing patient consultations.

2) Initial lab work is required, lab work will need to be repeated between 5 to 7 weeks after initial hormone replacement therapy protocol has been started, and then maintained every 6 months afterwards to be reviewed with a medical provider in a telehealth visit.

3) However, the practitioner might require additional and/or more frequent lab work testing based on my individual patient needs and/or medical conditions if applicable OR if additional peptide therapy or medication(s) are requested outside the traditional HRT protocol.

4) If at any time the practitioner feels a peptide or medication is no longer beneficial and/or it is detrimental to your health, it will be discussed during your consultation and removed from your protocol.

5) If a patient does not have the required lab work completed within the specified time frame, he/she will not be able to refill their hormone replacement therapy protocol until required lab work is completed, submitted and reviewed on a telehealth visit with their respective medical practitioner.

6) If a patient’s hormone levels do not fall below the standard for hormone optimization, off-label and additional lab tests will be required to determine if a patient is a candidate for hormone replacement therapy (HRT) with Ikigai Energy, LLC. This will be discussed in review of lab work submitted prior to the initial telehealth consultation.

7) If a patient does not perform therapeutic phlebotomies performed at least 2-4 times a year or acquired lab work results are unstable, hormone replacement therapy (HRT) will be adjusted and/or held until lab work results show improvement and stability, or proper treatment is obtained.

8) If a patient deviates from or does not follow recommended hormone replacement therapy (HRT) protocol and puts his/her health at risk, they will be considered a non-compliant patient and Ikigai Energy, LLC will reserve the right to terminate services effective immediately without written consent.

X

Cancellation Policy

I, understand and acknowledge the importance of adhering to the cancellation policy of Ikigai Energy to ensure efficient scheduling and respect for both my time and the Ikigai Energy's time. By signing below, I agree to the terms outlined in this policy.

I must provide a minimum of 24 hours’ notice if I need to cancel or reschedule my appointment. This enables Ikigai Energy to accommodate other clients and adjust schedules accordingly.

I understand that a "no-show" occurs when I miss an appointment without a minimum of 24 hour notice. In the event of a “no-show”, I acknowledge that I will be charged $100 cancellation fee. I also understand that future appointments may require prepayment to secure the reservation

I acknowledge that if I arrive late more than 15 minutes may be treated as a “no-show”, subject to the corresponding fee(s) outlined above.

I acknowledge that cancellations made within 24 hours of my appointment will be subject to a $100 cancellation fee

X

Disclosure and Consent Form

I hereby authorize the Ikigai Energy, LLC clinic staff to order Hormone Replacement Therapy (HRT) medication(s) on my behalf from the dispensing provider and pharmacy utilized by Ikigai Energy, LLC. I authorize the delivery of my medications and refills to me as prescribed/recommended by my provider. I understand that the neither the provider, the pharmacy, nor Ikigai Energy, LLC is responsible for lost or damaged goods and all issues regarding mail delivery shall be handled through the mailing company used.

This authorization will remain active for the course of my treatment at this clinic and renewed on an annual basis or until I revoke it in writing.

No Guarantee of Services: Ikigai Energy, LLC does not guarantee that any services or medication(s) will be provided to you until you have undergone the full preliminary sign-up process. This process is inclusive of all necessary submission of lab work and medical provider’s consultation and evaluation. At the provider’s discretion you will be provided medication(s) and/or services during your program at Ikigai Energy, LLC.

No Refund Policy: Ikigai Energy, LLC reserves the right to have NO RETURN and NO REFUND policy. Hormone Replacement Therapy (HRT) is approved by the FDA for prescribed hormonal deficiencies only. Using it for other symptoms or problems is considered “off-label” use and Ikigai Energy, LLC and inclusive staff will not be held responsible for “off-label” or use otherwise not indicated by consultation and prescription. When hormone replacement therapy is utilized and monitored properly and hormone levels are optimized for your age, there is much suggestive evidence that your overall health will improve.

Potential side effects: Acne, Breast/nipple soreness, decreased sperm count caused by exogenous testosterone regardless of HCG/Gonadorelin use, Excessive hair growth, Gynecomastia can be genetic due to higher levels of estrogen conversion, Increased blood pressure can be due to elevated hematocrit, possibility of increased prostate specific antigen (PSA) due to stimulation (sexual activity, heavy exercise, etc).

The above mentioned will be monitored and will be referred to your primary care physician for further evaluation if PSA is elevated or your specific medical condition warrants; your Hormone Replacement Therapy (HRT) may be put on hold until medically cleared. Increased red blood cell production which leads to elevated hemoglobin and/or hematocrit. Testosterone increases red blood cell production and routine blood donations or therapeutic phlebotomies will be needed at least 3-4 times a year. Irritability can be related to estradiol imbalance. Pain and swelling at injection site. Initial irritation due to improper cleaning techniques or sensitivity to a carrier oil. If not resolved with adjustments, then you will be asked to follow up with your primary care physician for any antibiotics that may be required. Testicular shrinkage is common in approximately 20% of male patients. Water retention/bloating can occur and can be related to estradiol imbalance. A weight gain of 2-5 pounds is common due to a potential increase in muscle mass.

Caution: If you are pregnant, intend to become pregnant, or are breastfeeding, Hormone Replacement Therapy (HRT) is not recommended.

X

HIPAA Authorization

Authorization for Use and Disclosure of Personal Health Information

This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. section 1320d, et seq., and regulations promulgated there under, as amended from time to time (collectively referred to as “HIPAA”).

This authorization affects your rights in the privacy of your personal healthcare information. Please read it carefully before signing. Ikigai Energy, LLC will not condition treatment,
payment, enrollment in a health plan, or eligibility for benefits as applicable, on you providing authorization for the requested use or disclosure.

You May Refuse To Sign This Authorization.

By signing this authorization, you acknowledge and agree that Ikigai Energy, LLC may use or disclose your personal healthcare information for the purpose(s) of treatment, payment and operation at Ikigai Energy, LLC.

By signing this authorization, you agree that Ikigai Energy, LLC may disclose your personal healthcare information to those recipients who need it for treatment, payment, and/or operations. Further by signing this authorization you acknowledge that Ikigai Energy, LLC Authorization for Use and Disclosure of Personal Health Information containing a complete description of your rights.

In accordance with your rights under, and subject to certain restrictions imposed by HIPAA, you may inspect or copy your PHI in the designated record set maintained by Ikigai Energy, LLC for as long as the PHI is maintained in the designated record set.

You have the right to revoke this authorization, in writing, at any time, except to the extent that Ikigai Energy, LLC has acted in reliance on it. A revocation is effective upon receipt by Ikigai Energy, LLC of a written request to revoke and a copy of the executed authorization form to be revoked at the address listed above. Authorization shall expire upon the earlier occurrence of: revocation of the authorization, a finding by the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights that this authorization is not in compliance with requirements of HIPAA Complete satisfaction of the purposes for which this authorization was originally obtained, to be determined in the reasonable discretion of Ikigai Energy, LLC or six years from the date this authorization was executed.

X

Telehealth Consent

Ikigai Energy, LLC located at 812 E. Oskaloosa Street, Pella, Iowa 50219 utilizes telehealth services to provide high quality care to all its patient(s). Telehealth, also known as telemedicine, involves the use of electronic communications to enable health care providers in various locations to share patient information for diagnostic purposes, therapy recommendations, follow up consultations, and/or patient education. The medical practitioners involved in my care may include but are not limited to a supervising physician, physician’s assistants, nurse practitioners, registered nurses, medical assistants, and other HIPAA certified professionals.

Telemedicine requires transmission of health information through the internet via electronic devices ranging from computers to handheld devices and may include:

1) Provider progress reports

2) Assessments

3) Other intervention related documents

4) Bio-physiological data transmitted electronically

5) Videos, pictures, text messages, audio

6) Any digital form of data

The laws that are currently in place for protected health information will be applied to the data obtained during a telehealth visit. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing, and healthcare operations.

As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of my identity and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

Telehealth sessions may not always be possible due to disruptions of signals or problems with the Internet’s infrastructure. Issues related to this may cause problems such as poor picture or sound quality, dropped connections, audio interference that prevent effective interaction between consulting clinician(s), patient, or care team.

Telehealth sessions may also be conducted by phone. With the agreement and permission by the patient. By signing this document, you are agreeing to this statement and wish to proceed with your Telehealth visits (by phone) with Ikigai Energy, LLC practitioners and clinical staff.