HRT PROGRAM ORDER FORMS

Transcription

1 A G ANAG A N A G C R S HRT PROGRA ORDR FORS THRAPY PROGRA GUIDLINS AND ORDR PROCDURS

2 A G ANAG A N A G C R S THRAPY PROGRA ORDR PROCDURS YOUR CONSULTANT S NA: RAD AND SIGN DICAL ANAGNT AGRNT COPLT QUALITY OF LIF ASSSSNT COPLT CONFIDNTIAL DICAL HISTORY INFORATION RAD AND SIGN PATINT AUTHORIZATION AGRNT SCHDUL PHYSICAL XAINATION SLCT PROGRA SLCT PAYNT THOD (credit card or wire transfer) COPLT SHIPPING INFORATION AND SIGN AIL FORS OR FAX TO: OPTIAL HALTH RJUVNATION CNTR, LLC OPTIAL HALTH & RJUVNATION CNTR CONTACT INFORATION: AIL INFORATION: Hallandale Beach Blvd Hallandale Beach, FL DIRCT LIN: (954) FAX LIN: (954) Optimal Health D, LLC , All Rights Reserved.

3 A G ANAG A N A G C R S ORDR FOR ONITROP - HUAN GROWTH HORON THRAPY Optimal Health and Rejuvenation Center offers many physician prescribed and medically supervised human growth hormone (HGH) replacement programs helping patients enter a cost effective and comprehensive age management and physical development program. HGH is one of several endocrine hormones such as estrogen, testosterone, melatonin and DHA that decline in production as we age. While many of these hormones can be replaced to deter some of the effects of aging, HGH goes far beyond the effect of any one of these hormones to not only retard biological aging but also to significantly reverse many of the effects of aging. Researchers have proven that HGH therapy can reverse the effects of aging by as much as 20 years with less than one year of treatment. HGH replacement therapy is the key to rejuvenation and to adding years of vitality on to your life. HGH is the key for life extension and age regression. Hormones can be thought of as "messengers" that are produced by the endocrine glands and then sent all over the body to stimulate specified activities. For example, growth, digestion, reproduction, and sexual functions are all triggered by hormones. As its name suggests, HGH is an endocrine hormone that makes humans grow. HGH is a complex protein molecule of 191 amino acids linked in a specific sequence. It is secreted in pulses by the pituitary gland. These pulses vary between 10 and 30 per day and can be strengthened by exercise. For years, doctors have prescribed HGH for children who needed a growth boost. HGH is critical for tissue repair, healing, muscle growth, bone strength, brain function, physical and mental health, energy, and metabolism. Somatropin is the man-made version of HGH. ach manufacturer of somatropin assigns its own brand name, such as Genotropin, Humatrope, Norditropin, Saizen, and Serostim. They are available only by prescription and administered by injection. HGH is produced at a rate that peaks during adolescence, at time when normal growth is accelerated. The production of HGH decreases with age. Humans normally produce about 500 micrograms of HGH daily at age 20. By age 80, the daily production falls to 60 (or less) micrograms. Our goal at Optimal Health and Rejuvenation Center is to increase levels of HGH to the upper normal range. This can easily be achieved through one of our medically supervised programs listed below. Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 90 lus of ONITROP (1 IU per day X 7 $20.00 per IU $ 1, Week 140 lus of ONITROP (2 IU per day X 5 $19.50 per IU $ 2, Week 210 lus of ONITROP (1 IU per day X 7 $18.00 per IU $ 3, Week 480 lus of ONITROP (2 IU per day X 5 $17.50 per IU $ 8, Week 560 lus of ONITROP (2 IU per day X 5 $17.00 per IU $ 9,520 NORDIFLX PN $27.00 per lu $ NORDIFLX PN $27.00 per IU $ TOTAL COST OF ONITROP (HGH) THRAPY PROGRA $ *A prescription is required for the purchase of syringes in the following states: California, Connecticut, Delaware, Hawaii, Idaho, Illinois, assachusetts, ichigan, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, & Rhode Island. Patients located in other States may be able to purchase syringes without a prescription at local pharmacies. HGH will only be dispensed from a licensed US Pharmacy with express delivery via Fedx Optimal Health D, LLC. [2]

4 A G ANAG A N A G C R S ORDR FOR TV- TROPIN - HUAN GROWTH HORON THRAPY Optimal Health and Rejuvenation Center offers many physician prescribed and medically supervised human growth hormone (HGH) replacement programs helping patients enter a cost effective and comprehensive age management and physical development program. HGH is one of several endocrine hormones such as estrogen, testosterone, melatonin and DHA that decline in production as we age. While many of these hormones can be replaced to deter some of the effects of aging, HGH goes far beyond the effect of any one of these hormones to not only retard biological aging but also to significantly reverse many of the effects of aging. Researchers have proven that HGH therapy can reverse the effects of aging by as much as 20 years with less than one year of treatment. HGH replacement therapy is the key to rejuvenation and to adding years of vitality on to your life. HGH is the key for life extension and age regression. Hormones can be thought of as "messengers" that are produced by the endocrine glands and then sent all over the body to stimulate specified activities. For example, growth, digestion, reproduction, and sexual functions are all triggered by hormones. As its name suggests, HGH is an endocrine hormone that makes humans grow. HGH is a complex protein molecule of 191 amino acids linked in a specific sequence. It is secreted in pulses by the pituitary gland. These pulses vary between 10 and 30 per day and can be strengthened by exercise. For years, doctors have prescribed HGH for children who needed a growth boost. HGH is critical for tissue repair, healing, muscle growth, bone strength, brain function, physical and mental health, energy, and metabolism. Somatropin is the man-made version of HGH. ach manufacturer of somatropin assigns its own brand name, such as Genotropin, Humatrope, Norditropin, Saizen, and Serostim. They are available only by prescription and administered by injection. HGH is produced at a rate that peaks during adolescence, at time when normal growth is accelerated. The production of HGH decreases with age. Humans normally produce about 500 micrograms of HGH daily at age 20. By age 80, the daily production falls to 60 (or less) micrograms. Our goal at Optimal Health and Rejuvenation Center is to increase levels of HGH to the upper normal range. This can easily be achieved through one of our medically supervised programs listed below. Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 60 lus of TV-TROPIN $20.00 per IU $ 1, Week 120 lus of TV-TROPIN $19.00 per IU $ 2, Week 240 lus of TV-TROPIN $18.00 per IU $ 4, Week 360 lus of TV-TROPIN $ per IU $ 6, Week 480 lus of TV-TROPIN $16.00 per IU $ 7, Week 600 lus of TV-TROPIN $15.00 per IU $ 9,000 NORDIFLX PN $22.00 per IU $ TOTAL COST OF ONITROP (HGH) THRAPY PROGRA $ *A prescription is required for the purchase of syringes in the following states: California, Connecticut, Delaware, Hawaii, Idaho, Illinois, assachusetts, ichigan, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, & Rhode Island. Patients located in other States may be able to purchase syringes without a prescription at local pharmacies. HGH will only be dispensed from a licensed US Pharmacy with express delivery via Fedx Optimal Health D, LLC. [3]

5 A G ANAG A N A G C R S ORDR FOR TSTOSTRON GL THRAPY Testosterone production declines naturally with age. The more we age the less our bodies produce. Testosterone deficiency (TD) may result from disease or damage to the hypothalamus, pituitary gland, or testicles that inhibits hormone secretion and testosterone production, also known as hypogonadism. Depending on age, insufficient testosterone production can lead to abnormalities in muscle and bone development, underdeveloped genitalia, and diminished virility. Testosterone is the androgenic hormone primarily responsible for normal growth and development of male sex and reproductive organs, including the penis, testicles, scrotum, prostate, and seminal vesicles. It facilitates the development of secondary male sex characteristics such as musculature, bone mass, fat distribution, hair patterns, laryngeal enlargement, and vocal chord thickening. Additionally, normal testosterone levels maintain energy level, healthy mood, zest for life, fertility, and sexual desire. Testosterone production increases rapidly at the onset of puberty and starts to decrease there after. It decreases rapidly after age 40 (to 20% to 70% of peak level by age 70). Approximately 8 million men in the United States experience testosterone deficiency; approximately 700,000 receive treatment. The testosterone gel is a clear, colorless alcohol based gel that gets applied once daily to the skin. Upon application, it dries within a few minutes. The skin absorbs the testosterone and serves as a reservoir for the hormone, which slowly enters the bloodstream. Normal testosterone levels are achieved soon after application for most men. One can experience a significant increase in libido (sex drive) as well as improvements in the quality and duration of erections, also increased lean body mass, reduced fatigue, increase bone density, energy levels, muscle strength and endurance. The pure, micronized testosterone gel enables the patient to safely maintain a consistent level of testosterone. The testosterone gels offer a safe and effective needle free way to administer testosterone and dose not cause fluctuating levels of testosterone caused by injections. Testosterone gel represents the newest technology in advance pharmacology and hormone delivery systems. It is compounded in the US by licensed pharmacies pursuant to a medical prescription. ach patient is first required to have a physical examination and lab work (blood sample/urine test). A physical examination and lab work are required to determine if a prescription will be issued for a testosterone therapy program. You may visit to our physician's office or to have a Porta-edic (Nurse practitioner/physician services) come to your home or office. You must have the required lab work and complete the required medical history form to have a prescription approved by our physician and dispensed by the pharmacy. Please note: 100% of program costs are returned to patient if reviewing physician disqualifies the patient for treatment. PHAS 1 Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ onths of testosterone gel dispensed incrementally by a licensed US pharmacy $ 995 One year of testosterone gel dispensed incrementally by a licensed US pharmacy $ 1,595 PHAS 2 [HCG] Human Chorionic Gonadotropin. Used to stimulate production of endogenous testosterone. Testosterone is used in treatment cycled with HCG in Testosterone Replacement Therapy (TRT). Sufficient HCG prescribed to properly cycle with 24,000 mg of testosterone cream over 12 month period. 30,000 units. 6 months of HCG dispensed incrementally by licensed US pharmacy $ ,000 units. One year of HCG dispensed incrementally by licensed US pharmacy $ 595 TOTAL COST OF TSTOSTRON RPLACNT THRAPY PROGRA $ Testosterone will only be dispensed from a licensed US Pharmacy with express delivery via Fedx Optimal Health D, LLC. [4]

6 A G ANAG A N A G C R S ORDR FOR TSTOSTRON INJCTABL THRAPY Testosterone production declines naturally with age. The more we age the less our bodies produce. Testosterone deficiency (TD) may result from disease or damage to the hypothalamus, pituitary gland, or testicles that inhibits hormone secretion and testosterone production, also known as hypogonadism. Depending on age, insufficient testosterone production can lead to abnormalities in muscle and bone development, underdeveloped genitalia, and diminished virility. Testosterone is the androgenic hormone primarily responsible for normal growth and development of male sex and reproductive organs, including the penis, testicles, scrotum, prostate, and seminal vesicles. It facilitates the development of secondary male sex characteristics such as musculature, bone mass, fat distribution, hair patterns, laryngeal enlargement, and vocal chord thickening. Additionally, normal testosterone levels maintain energy level, healthy mood, zest for life, fertility, and sexual desire. Testosterone production increases rapidly at the onset of puberty and starts to decrease there after. It decreases rapidly after age 40 (to 20% to 70% of peak level by age 70). Approximately 8 million men in the United States experience testosterone deficiency; approximately 700,000 receive treatment. Treatment involves testosterone replacement therapy. The method of delivery is determined by age and duration of deficiency. Optimal Health and Rejuvenation Center offers many testosterone replacement therapy programs to those who qualify. The testosterone supplies we use are all manufactured in the US by licensed pharmacies. Testosterone is injected intramuscularly in a prescribed medical treatment cycle along with HCG and estrogen blockers. Dosage and duration of therapy depend upon, age, diagnosis, patient's response to therapy, and avoidance of adverse side effects. Testosterone is dispensed in single vials pursuant to a physician's prescription. Dosage rate and duration of therapy depend upon age, diagnosis, response to therapy, and avoidance of any adverse side effects. We provide testosterone for injections that has been compounded in the US by licensed pharmacies and prescribed by US physicians for use by patients in the United States. ach patient is required to have a physical examination and lab work (blood sample/urine test). A physical examination and lab work are required to determine if a prescription will be issued for a testosterone therapy program. You may visit to our physician's office or to have a Porta-edic (Nurse practitioner/physician services) come to your home or office. You must have the required lab work and complete the required medical history form to have a prescription approved by our physician and dispensed by the pharmacy. Please note: 100% of program costs are returned to patient if the reviewing physician disqualifies the patient for treatment. PHAS 1 Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ 495 5,000 mg. 6 months of testosterone dispensed incrementally by licensed US pharmacy $ ,000 mg. One year of testosterone dispensed incrementally by licensed US pharmacy $ 1,495 PHAS 2 [HCG] Human Chorionic Gonadotropin. Used to stimulate production of endogenous testosterone. Testosterone is used in treatment cycled with HCG in Testosterone Replacement Therapy (TRT). Sufficient HCG prescribed to properly cycle with testosterone replacement program. Physician services and HCG prescription $ 75 25,000 mg. 6 months of HCG dispensed incrementally by licensed US pharmacy $ ,000 mg. Per year, one year of HCG dispensed incrementally by licensed US pharmacy $ 595 TOTAL COST OF TSTOSTRON RPLACNT THRAPY PROGRA $ Testosterone will only be dispensed from a licensed US Pharmacy with express delivery via Fedx Optimal Health D, LLC. [5]

7 A G ANAG A N A G C R S ORDR FOR ONITROP ( HGH) and TSTOSTRON COPLT THRAPY PROGRA The combination of HGH with testosterone and other hormones like DHA, melatonin etc., is by far the most effective when compared to single hormone therapy. Scientists and age management doctors believe that this synergistic effect occurs because growth hormone pushes the testosterone (and other hormones) into the tissues and cells where they are needed. This increases the effectiveness of almost any kind of replacement therapy. The interesting thing here is that HGH levels are restored to optimum levels when other key male hormones, such as testosterone, are also replaced. The use of both HGH and testosterone compliment each other very well, this synergistic approach delivers results and benefits in an effective and expedited way. 14 WK COPLT HGH/TSTOSTRON PROGRA Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 140 lu s - ONITROP (HGH) $ per IU 1 x 10cc vials - Testosterone (Cypionate) dispensed incrementally by licensed US pharmacy 10,000 units of HCG dispensed incrementally by licensed US pharmacy $ 2, WK COPLT ONITROP (HGH) and TSTOSTRON PROGRA Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 260 lu s - ONITROP (HGH) $ per IU 2 x 10cc vials - Testosterone (Cypionate) dispensed incrementally by licensed US pharmacy 20,000 units of HCG dispensed incrementally by licensed US pharmacy $ 5, WK COPLT ONITROP (HGH) and TSTOSTRON PROGRA Physical exam, labwork and analysis including baseline evaluation to determine hormonal levels $ Week 480 lu s - ONITROP (HGH) $ per IU 4 x 10cc vials - Testosterone (Cypionate) 200mg dispensed incrementally by licensed US pharmacy 50,000 units of HCG dispensed incrementally by licensed US pharmacy $ 10, WK COPLT NORDIFLX (HGH) and TSTOSTRON PROGRA Physical exam, labwork and analysis including baseline evaluation to determine hormonal levels $ 495 NORDIFLX PN 5G or $22.00 per IU $ 6 x 10cc vials - Testosterone (Cypionate) 200mg dispensed incrementally by licensed US pharmacy 60,000 units of HCG dispensed incrementally by licensed US pharmacy $ 10,995 TOTAL COST OF HGH / TSTOSTRON COPLT THRAPY PROGRAS $ HGH and/or Testosterone will only be dispensed from a licensed US pharmacy with express delivery via Fedx Optimal Health D, LLC. [6]

8 A G ANAG A N A G C R S ORDR FOR TV- TROPIN 5mg ( HGH) and TSTOSTRON COPLT THRAPY PROGRA The combination of HGH with testosterone and other hormones like DHA, melatonin etc., is by far the most effective when compared to single hormone therapy. Scientists and age management doctors believe that this synergistic effect occurs because growth hormone pushes the testosterone (and other hormones) into the tissues and cells where they are needed. This increases the effectiveness of almost any kind of replacement therapy. The interesting thing here is that HGH levels are restored to optimum levels when other key male hormones, such as testosterone, are also replaced. The use of both HGH and testosterone compliment each other very well, this synergistic approach delivers results and benefits in an effective and expedited way. 12 WK COPLT TV- TROPIN ( HGH) andtstostron PROGRA Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 120 lu s - TV-TROPIN (HGH) $ per IU 1 x 10cc vials - Testosterone (Cypionate) dispensed incrementally by licensed US pharmacy 10,000 units of HCG dispensed incrementally by licensed US pharmacy $ 2, WK COPLT TV- TROPIN ( HGH) and TSTOSTRON PROGRA Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 240 lu s - TV-TROPIN (HGH) $ per IU 2 x 10cc vials - Testosterone (Cypionate) dispensed incrementally by licensed US pharmacy 20,000 units of HCG dispensed incrementally by licensed US pharmacy $ 4, WK COPLT TV- TROPIN ( HGH) andtstostron PROGRA Physical exam, labwork and analysis including baseline evaluation to determine hormonal levels $ Week 480 lu s - TV-TROPIN (HGH) $ per IU 4 x 10cc vials - Testosterone (Cypionate) 200mg dispensed incrementally by licensed US pharmacy 40,000 units of HCG dispensed incrementally by licensed US pharmacy $ 7, WK COPLT TV-TROPIN (HGH) andtstostron PROGRA Physical exam, labwork and analysis including baseline evaluation to determine hormonal levels $ Week 600 lu s - TV-TROPIN (HGH) $ per IU 6 x 10cc vials - Testosterone (Cypionate) 200mg dispensed incrementally by licensed US pharmacy 60,000 units of HCG dispensed incrementally by licensed US pharmacy $ 10,995 TOTAL COST OF HGH / TSTOSTRON COPLT THRAPY PROGRAS $ HGH and/or Testosterone will only be dispensed from a licensed US pharmacy with express delivery via Fedx Optimal Health D, LLC. [7]

9 A G ANAG A N A G C R S ORDR FOR SRORLIN HGH / RLASR THRAPY PROGRA Restoring optimal levels of growth hormone may improve or sustain good youthful anatomy, physiology, and thereby, the health and vitality often lost with age-related growth hormone deficiency. Traditionally, adult growth hormone deficiency (AGHD) has been treated by substituting natural hgh with recombinant human growth hormone (rhgh). Although rhgh injections are still the standard for treating AGHD, a breakthrough product, Sermorelin, offers a more natural, affordable alternative that is as effective as rhgh therapy. Developed in 1998 by Serono Laboratories, Inc., the makers of Saizen hgh, FDA approved Sermorelin has recently become available for the treatment of AGHD. Sermorelin is comprised of 29 amino acids found in the hormone (GRF 1-44) that your brain produces naturally to simulate the release of hgh. As a growth hormone releasing agent, Sermorelin triggers the pituitary gland to produce your own natural hgh. In this natural process, your body reguletes the level and frecuency of hgh release, so there are no side effects associated with the constant application of injected rhgh Sermorelin requires no off-cycles. In fact, the longer you use it, the better your pituitary gland functions, more like it when you were younger. Bottom line, Sermorelin effectively re-starts your natural hgh production to levels produced when you were younger COPLT SRORLIN PROGRA Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 6 Vials - SRORLIN $ per Vial $ COPLT SRORLIN PROGRA Baseline evaluation, physical exam, labwork analysis to determine hormonal levels and prescription $ Week 12 Vials - SRORLIN $ per Vial $ 1, COPLT SRORLIN PROGRA Physical exam, labwork and analysis including baseline evaluation to determine hormonal levels $ Week 24 Vials - SRORLIN $ per Vial $ 2,700 TOTAL COST OF HGH / TSTOSTRON COPLT THRAPY PROGRAS $ HGH and/or Testosterone will only be dispensed from a licensed US pharmacy with express delivery via Fedx Optimal Health D, LLC. [8]

10 A G ANAG A N A G C R S AIL ORDR AGRNT AIL ORDR/ PATINT AGRNT FOR PURCHAS OF PRSCRIBD DRUGS LABORATORY TST AND PHYSICIAN SRVICS Patient Agreement and ail Order Purchase Instructions: 1. Fax copy of the completed ail Order Forms including Signature Page to: (954) Fax copy of completed edical History Form to: (954) Fax copy of signed Authorization for edical Care and Treatment to: (954) Send payment as instructed on the enclosed forms for wire transfers or pay by credit card. 5. Fax copy of your completed wire transfer instructions or credit card form to (954) If you elect to pay by wire transfer, the original wire transfer form must be delivered to your bank so that the bank can send the wire transfer of funds from your account to our office. 6. Phone our office after you have made the wire transfer or credit card payment to us and arrange for a physical exam and lab work (unless you can provide valid lab work by U.S Clinic or lab, lab work may not be required for your specific prescription.) 7. If you purchase a blood test or treatment, a licensed medical doctor will review your medical records and any lab work results for the purpose of issuing a prescription. 8. You have the option to purchase only the blood test and physician services and wait to be advised as to whether your requested prescription have been issued by a reviewing medical doctor. 9. If you purchased and receive physician services, lab work, and a medical program, (growth hormone or testosterone) then 100% of your funds shall be returned if your sought prescription is not granted after our receipt of your blood test results. 10. Purchaser understands and agrees that no purchase funds for any purchased medical program shall be returned to any purchaser after the prescription has been granted once we are in receipt of payment for any reason. 11. Please allow up to 3 business days for express overnight delivery after our receipt of your prescription. 12. Seller makes no claims to purchaser, or seller s agents, as to any benefits to be obtained by a specific individual with respect to pharmaceuticals prescribed or purchased from our affiliated organizations or Optimal Health D, LLC. 13. Delivery is guaranteed to U.S. purchasers. Foreign purchasers are responsible for clearing customs in their own country with respect to their prescription purchase. Delivery of growth hormone is guaranteed to purchasers in the U. S. 14. U.S. pharmacies may dispense directly to purchaser pursuant to a prescription of a U.S. physician prescribed U.S. approved drugs purchased through Optimal Health D, LLC. or our affiliated organizations. 15. Testosterone shall be dispensed directly to patient by a U.S. pharmacy pursuant to a prescription of a U.S. physician based on medical evaluation, patient medical history, diagnostic exam and current laboratory blood test. 16. Human Growth Hormone (HGH) is prescribed in the U.S. for disease and recognized medical conditions. Human Growth Hormone (HGH) shall be dispensed directly to patient by a U.S. pharmacy pursuant to a prescription of a U.S. physician based on medical evaluation, patient medical history, diagnostic exam and current laboratory blood test. Please note: Requests for human growth hormone, may include a laboratory blood test fee if blood test requested by either patient, or treating physician, to ascertain patients current blood levels of growth hormone and IGF $495 Requests for testosterone must include annual physician fee, laboratory blood test fee, and annual prescription and refill fees totaling $ 495 Total amount due including fees $ Please Sign Your Name: Please Print Your Name: Signature of Purchasing Patient Required Date: Optimal Health D, LLC. [9]

11 A G ANAG A N A G C R S WIR TRANSFR FOR BANK WIR TRANSFR AUTHORIZATION FOR Date: onth / Day / Year Amount Purchased:...$ Add 5% of Purchased Amount for Shipping and Insurance:...$ Total Including Insurance and Shipping 5% fee:...$ Bank Wire Information: Bank of America 1900 Tyler Street Hollywood, FL Optimal Health D Hallandale Beach Blvd Hallandale Beach, FL 3309 Routing number: # Bank Account: # Transaction Confirmation Receipt: Name: Please Sign Your Name Please Print Your Name Phone Number: Home ( ) Work ( ) Purchaser agrees that no wire transfer payment transaction shall be disputed by purchaser for any reason after the wire transfer payment transaction has occurred and that patient shall not be entitled to a return of any purchase funds paid by credit card for any reason. Patient irrevocably waives any right to dispute charge. Optimal Health D, LLC. [10]

12 A G ANAG A N A G C R S BANK PAYNT FOR BANK PAYNT AUTHORIZATION DIRCT DPOSIT INFORATION: Optimal Health D Hallandale Beach Blvd Hallandale, FL Tel: (954) Fax: (954) Bank of America 1900 Tyler Street Hollywood, FL Tel: (954) Tol: (888) Wire Routing: # *For Domestic Wires Only Direct Deposit ROUTING: # *For Direct Deposit at Bank of America Branch A/R ACCT#: Transaction Receipt: Name: Please Sign Your Name Name: Please Print Your Name Phone Number: Home ( ) Work ( ) Purchaser agrees that no bank deposit and/or wire transfer payment transaction shall be disputed by purchaser for any reason after the wire transfer payment transaction has occurred and that patient shall not be entitled to a return of any purchase funds paid by credit card for any reason. Patient irrevocably waives any right to dispute charge. Optimal Health D, LLC. [11]