vorpal CLIENT PAPERWORK OVERVIEW INTRODUCTION LETTER. Client Notification. Primary and Urgent Care. BNHC Care. Business Days and Office Hours. Labs and Tests. Payment. Initial Consultation. Requested Materials. Virtual Appoiniments.. Cancellations, No-Shows, and Rescheduling. Follow-up Appointment Requirement Introduction Letter Signature Page CLIENT REGISTRATION. CONSENT TO RELEASE CONFIDENTIAL INFORMATION. CONSENT FOR EVALUATION AND TREATMENT. CANCELLATION, RESCHEDULE, AND NO-SHOW POLICY. CREDIT CARD AUTHORIZATION. NOTICE OF PRIVACY PRACTICES (HIPAA Privacy Statement) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES CUNIC FEE SCHEDULE. HEALTH SUMMARY. PART 1: Physicians PART 2: Medications and Supplements PART 3: Chronological Case History PART 4: Chronological Event History PART 5: Metabolic Assessment Form INFORMED CONSENT. EMAIL AND MESSAGING POLICY. TERMS OF SERVICE. ONLINE CLIENT AREA. BNBSSRS ON anabrsawwwNNNS & 8eeRMeas Dr. Jodie A. Dashore PhD (Integrative Medicine), OTD (Neurology), HHP, BCIP, CCH, RH (AHG) Board Cortifed Integrative Pediatrics Board Certified Holistic Health Practitioner Registered Herbalist American Herbalist Guild IRS Certified Practitioner Member International Lyme and Associated Diseases Society ILADS Biop INTRODUCTION LETTER Deer Client: Welcome to BioNexus Health! We want to take this opportunity to provide you, the Adult Client and/or minor Client's Guardian (collectively, “Client” or “You"), with the necessary information regarding your upcoming appointment and continuation as a client. To make your appointments as productive as possible. please read this Introduction Letter and all the enclosed documents very carefully and as soon as possible to avoid appointment disruption or additional fees. IMPORTANT: review, complete, and returnall the enclosed documents. BioNexus Health Clinic, LLC (“BNHC.” “We.” or “Our’)is a boutique practice that helps clients in over 50 countries. BNHC maintains a small support stafFand needs to optimize their working hours for the best bencfit of all of our clients. BNHC policies help streamline the practice to benefit all of BNHC clients. It is important to BNHC that every client respects the care other clients. You can help by following all of the policies, just as we expect others to do for you. Client Notification Atthis time, we would like to remind, reaffirm, and/or inform you of critical BNHC policies. BNHC requires all Requested Materials listed under the “Request Materials” section, which includes but is aot limited to completed forms and any additional requested materials to arrive at the BNHC office at least seven days before your appointment. BNHC does NOT accept anv insurance. All deposits are non-refundable and non- transferable, however, it will be deducted from the cost of your appointment at the time of your ‘appointment. Please carefully mark the appointment date on your calendar. The initial consultation is final and there is no rescheduling. International Patients, please note that all payments are non-refundable and non-transferable. Because BNHC maintains a small staff, BNHC does NOT offer reminder calls, emails, or text (SMS) messages. The Client is solely responsible for noting the accuzate time and date of the confirmed appointment. BNHC reserves the right to refuse service to anyone who fails to follow the BNHC. policies as written in the enclosed documents, including “Requested Materials” agreements; and any updates that may follow. This rule applies to those who do not respect the doctor's time and the time needed to care for all of BNHC clients. Please, use your allotted time effectively. NO recording of any kind is permitted during the appointment er the advice from our legal team. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burlington Drnve, Suite L4, Marlboro, NI 07746 1 | PageSpecial note for those patients seeking help with mold/ biotoxin illness. Dr. Dashore is a CIRS certified practitioner in the Shoemaker protocol. Both, Dr. Shoemaker's and the BioNexus websites state accurately that she is not an MD but rather a PhD and practices all natural plant-based medicine approach Itis important tonote two options regarding treatment of mold /biotoxin illness: Option 1 ‘The BioNexus Approach to mold/biotoxin illness an all-natural plant-based treatment option for ‘mold toxicity and biotoxin illness. Most of our patients prefer to stay all-natural Option 2 ‘Those who wish to go with pharmaceuticals. Guidance with Dr. Shoemaker’ 12 step protocol. Primary care and specialist physicians refer their patients to Dr. Dashore for guidance with Dr. Shoemaker’s conventional protocol. Dr. Dashore is happy to help guide patients and practitioners with blood work and pharmaceuticals used in the conventional Shoemaker CIRS 12 step treatment protocol. Conversely, Dr. Dashore is happy to recommend collaborative and Imowiedgeable physicians who understand Dr. Shoemaker's protocol and appreciate Dr. Dashore’s expertise in plant-based therapies. In either case, Dr. Dashore helps with nutrition, wellness, diet, detoxification, environmental precautions, gut health, interpretation of lab tests, and guided overall CIRS treatment. Dr. Dashore’ s proprietary herbal treatment option for MARCoNS, Formula 1 NSB nasal spray, has been lab-tested and found to be a viable option for the treatment of MARCOoNS for those who prefer a natural altemative or have failed with other treatments. BNHC does not accept patients for legal cases at this time. Primary and Urgent Care BNHCis not your primary care doctor. It is important that you maintain a primary care doctor throughout your BNHC care. Contact your primary care doctor for routine care, including, ‘butnot limited to coughs and colds. BNHC also does not practice general or emergency‘urgent care medicine. Ifit is an ‘emergency, BNHC recommends visiting the nearest emergency room, calling your country's ‘emergency number for an ambulance, contacting your primary care physician, or another urgent care provider. It is the sole responsibility of the Client to attend their general and urgent medical needs and seek assistance when it is required. Business Days and Office Hours ‘Mondzy — Thursday 9am ~ 1 pm (USA Eastem time zone) Current official Business Days & Office Hours are posted on the BNHC website. See the Cancellation, Reschedule, and No-Show Policy to leam more. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 2|PageLabs and Tests BNHC will only review labs and tests with the Client during the appointment. Please do not ask forreview cutside of your appointment; the request will be denied. Copies of labs and tests will only be given to the Client during follow-up appointments. Please use the appointment time to ask BNHC any questions you may have about the lab or test results. It's recommended to prepare your questions and a pen and paper for notes. BNHC absolutely does not share BNHC chart notes with anyone outside of the BNHC office. The Client may review their chart notes during their appointment. Processing laboratories are required to forward the test results to the practitioner directly as per our office policy. Please understand that we will be happy to provide you with a copy of your lab results during or after your labs review appointment. BNHC only faxes lab and test results to other doctors. A request to send them anywhere ‘dlse will be denied. A request for one additional copy during your appointment will be charged @ Copy Fee per the Clinic Fee Schedule. No other copies will be provided. Payment In accordance with the Clinic Fee Schedule, the Client and/or their Client Financial Guarantor, as listed on Client Registration are responsible for maintaining a current account ‘balance by paying any and all invoices in a timely manner. Please thoroughly read and execute the Credit Card Authorization. BNHC requires 2 valid and cunt credit card on file. BNHC reserves the right to change the Clinic Fee Schedule. BNHC must provide Clieat with notification prior to the effective date as described in the Clinic Fee Schedule. Initial Consultation BNHC requires all Requested Materials to be FULLY COMPLETED and submitiedto BioNexus Health at least one week before your appointment unless otherwise specified. FAILURE to mest this deadline may result in an appointment cancellation fee as described in the Cancellation, Reschedule, and No-Show Policy. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 5|PageRequested Materials ‘The followings a list of all the required agreements that must artive at BNHC atleast one week prior to your appointment: Signed Introduction Letter: ‘Completed and signed Client Registration; ‘Completed and signed Consent To Release Confidential Information; ‘Completed and signed Consent for Evaluation and Treatment; Signed Cancellation, Reschedule, and No-Show Policy. Review HIPAA Privacy Statement; ‘Completed and signed Acknowledgment of Receipt of Notice of Privacy Practices; Signed Email Policy: ‘Completed, initialed, and signed Credit Card Authorization; Signed Clinic Fee Schedule; Initialed and signed Terms of Service: (Completed Health Summary. oooooo ooo oOo Please provide a copy of the following Additional Requested Materials: = front and back of Client’s valid government-issued identification; 2 front and back of credit card used on Credit Card Authorization form; 2 front and back of Credit Card Holder's valid govemment-issued identification; Virtual Appointments BNHC prefers Zoom (zoom.us). Zoom is available for several devices: desktop, tablet, and mobile. Zoom offers a test meeting at https://zoom.us‘test. Itis the sole responsibility of the Client to ensure their technology is working properly before the appointment, and they are waiting for the meeting “host” to artive before their appointment time. Please see the Cancellation, Reschedule, and No-Show Policy for more information. BNHC offers a helpful guide on the BNHC website (bionexushealth.com/zoom help): we in no way guarantee this information is up to date or correct. Direct all technical support questions to Zoom (support.z0om.us). Zoom offers instructive videos on their support page. Atleast 30 minutes before your appointment, install Zoom on your device from their download page (zoom.us/support/download) and test your speakers and microphone. ICONTINUES ON THE NEXT PAGE] November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 4|PageAtleast 15 minutes before your appointment, you should have received a meeting invitation email from the BNHC office. Follow the instructions below to join the appointment: open the meeting invitation email and click the meeting link inside of it: ™ thelink opens the Zoom meeting page for your appointment. You will receive 2 message on screen to wait for the “host,” the BNHC doctor, WM thereis a text link that will allow you totest your speakers and microphone, please check they are working before the appointment begins: when the “host” (BNHC doctor) joins the appointment a new message appears on your screen asking you to join the meeting. Click the green join audio conference by computer (er whatever device you are on) button; if your device asks to access your microphone or camera: confim, yes, or allow. Cancellations, No-Shows, and Rescheduling ‘The Client will review and acknowledge the strict BNHC cancellation, no-show, and rescheduling policies as so defined in the Cancellation, Reschedule, and No-Show Policy. Follow-up Appointment Requirement To remain listed as a Current BNHC Client, follow-up appointments are required a minimum of every three to four months depending on mutual availability. A two month grace period can be offered as a one time courtesy, ifrequested and circumstances warrant an ‘extension. Any Client who fails to meet the minimum follow-up requirement will be asked to repeat the Initial Consultation process, including paperwork and deposits BNHC requires Clients to Arrive at an appointment to remain an active Client. ‘The Client will be given copies of lab results and treatment instruction sheets during the follow-up appointment. only after being discussed with the doctor. It's recommended to prepare your questions and a pen and paper for notes. Ifyou have any questions regarding appointment or the Requested Materials, please contact the BNHC office via BNHC’s scheduling email. Please note that the Email Policy applies to these questions. Thank you for choosing BioNexus Health Clinic, LLC. We look forward to meeting you! Sincerely, BicNexus Health Clinic staff November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 S|PageIntroduction Letter Signature Page By signing below, I, the Client, attest that Ivead and understood all the information provided to Client by BNHC in the Introduction Letter, a quick start guide to the BNHC agreements that follow, that indudes the following sections: Client Notification; Primary and Urgent Care: BNHC Care; Business Days and Office Hours; Lebs and Tests; Payment; Initial Consultation; Request Materials: Virtual Appointments; Cancellations, No-Shows, and Rescheduling: Follow-up Appointments Requirement. ‘The Client confirms that they are of and in sound mind, cognitively aware, alert, have read and understand everything in the Introduction Letter. Allagreements and notices with and/or from BNHC, executed by Client may be executed in any number of counterparts (a copy is as effective as the original), and all Requested Materials Agreements supersede the Introduction Letter. Hf Adult Client, print name: Ifminor client, print name: Tfminor client, print name of Client’s Guardian: Signature of Adult Client or Client’s Guardian: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 o|PageCLIENT REGISTRATION Full Name of Client (“Adult Client” or Minor Client): IfMinor Client, Full Name of “Client Guardian”: IfMinor Client, Full Name of Client Guardian #2: Address: CLIENT INFO: ‘Marital Status: Single ‘Manied Gender: Male Female Date of Birth: Age: ADULT CLIENT OR CLIENT GUARDIAN: Email: Home Phone: Cell Phone: Emergency Contact CEC”) ECPhone Number: Employment Status: Employed Unemployed Retired Student Other Employer(“E"): E's Phot E Address: Client Financial Guarantor - Financially Responsible Individual (complete, even if Client) Name: Date of Birth: Address: Relationship to Client: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 T\PageClient Registration Signature Page By signing below, I, the Adult Client or Client Guardian, confirm the information provided on the Client Registration form is trueand accurate: If Adult Client, print name: Ifminor client, print name: Ifminor client, print name of Client's Guardian: Signature of Adult Client or Client's Guardian: Today's Date: By signing below. I. the Client Financial Guarantor. confirm the information provided. attest. and consent that | fully and completely agree, understand, and stipulate that: Client and/or the Client Financial Guarantor are solely responsible for making full and complete payment for any and all invoices provided by BNHC, unless otherwise provided ‘by law, any and all fees as so definedin the Clinic Fee Schedule that may accrue on Clieat’s account, and any other fee assessed per any and all Requested Materials Agreements. ™) BNHC reserves theright to charge the maximum interest rate allowed by Izw on all outstanding Client balances older than 30 days. ‘Name of Client Financial Guarantor: Signature of Client Financial Guarantor: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 $|PageCONSENT TO RELEASE CONFIDENTIAL INFORMATION (fall name of adult client or client's guardian, collectively, “Client”), do hereby authorize BioNexus Health Center, LLC (“BNHC”) to release and share any and all information pertinent to (ast name), (first name), (middle initial) ‘bom on (date of birth). Client's primary care physician: Primary care physician office phone: Primary care physician business name: Other important medical care professionals and/or family members: (use an additional page, ifneeded) ‘Name Phone Business name’Relationship By signing below, I, the Adult Client or Client's Guardian, confirm the information provided, attest, and consent that I fully and completely agree, understand, and stipulate that: Ml this release permits the medical professionals listed above to share information including, ‘batnot be limited to conversations, therapy sessions, records. reports, determinations, evaluations and factual information regarding the Client with BNHC. Ml this action assists BNHC to provide client care. Ml this authorization is voluntary and remains in effect until specifically revoked by written notice by the undersigned and that any counterpart, a copy is as effective as the original. If Adult Client, print name Ifminor client, print nam Ifminor client, print name of Client's Guardian: Signature of Adult Client or Client's Guardian: ‘Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 9|PageCONSENT FOR EVALUATION AND TREATMENT L. (fall name of Adult Client or Client’s Guardian, “Client") do hereby authorize BioNexus Health Center, LLC; Dr. Jodie A. Dashore, PhD, OTD, BCIP, HHP, BCIP, CCH, RH (AHG) (the “Doctor”); and whomever BNHC designates to assist as necessary in client care (collectively, “BNHC’), including but not limited to evaluations, observations, and treatments for ast name). (Girst name), (middle initial) bor on (date of birth) L. (fall name of Adult Client or Client’s Guardian) understand that Dr. Jodie A. Dashore holds both a Doctor of Philosophy PhD) in Integrative ‘Medicine and a Doctor of Occupational Therapy (OTD) specializing in Neurology, is Board Certified in Integrative Pediatrics (BCIP) and Board Certified Holistic Health Practitioner (HHP), however. does not hold a degree required to bea licensed medical doctor (Medical Degree - MD. or Doctors of Osteopathy - D.O.)in the United States of America. Additionally, I, (all name of Adult Client or Client's Guardian), understand and agree that: consultations are for educational and informational purposes only. each individual is biologically unique, and there are no guarantees forthe treatment success. health and accident insurance policies are an arrangement between an insurance cartier and Client. MM BNHC does not provide assistance with disability claims, lawsuits and/or legal matters, or insurance claims and/or insurance matters at any time. Client clinical and appointment notes cannot be faxedto any insurance company, disability company. andor an attamey’s office by the Client or BNEC staff. Client may share their invoice with their insurance company. Client must adhere to.all BNHC policies. @ = Client has read the Credit Card Authorization and further understands the convenience fee, Clinic Fee Schedule, and that BNHC requires all clients tokeep their client accounts current for BNHC to continue providing services. HM) BNHCteserves theright to deny services to and/or discharge any client non-complaint with BNHC policies and/or if the Doctor deems BNHC may not be 2 good match for that client's medical path. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 10|PageConsentfor Evaluation and Treatment Signature Page By signing below, I, the Client, attest and consent that fully and completely agree, understand, and stipulate to any and all terms on the Consent for Evaluation and Treatment form and its application to any and all treatments offered and given to the Client by BNHC. Adgitionally, and optionally. BNHC and the Doctor frequently participate in advancements of ‘medicine. By checking all or some of the boxes below, I, the Client, wouldlike to be informed of ways to participate. Tunderstand, even ifinformed, my participation is not mandatory, and an additional release and/or agreement will be required for Client's participation. BNHC medical research studies where Doctor is the lead researcher. NHC medical research studies where Doctor is a participant. Practitioner mentoring program where Doctor trains other Practitioners in BNHC. methods and approaches. 5 Other programs If Adult Client, print name: Tfminor client, print name: Ifminor client, print name of Client's Guardian: Signature of Adult Client or Client's Guardian: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 l1|PageCANCELLATION, RESCHEDULE, AND NO-SHOW POLICY BioNexus Health Clinic, LLC (“BNHC") requires Adequate Notice from Adult Client or Client's Guardian (collectively, “Client”) forany change of appointmens, including cancellations and reschedules (collectively, “Change Requests"). BNHC reserves the right to consider an appointment missed (“No-Show”) if a Client arrives more than 1 minute late for an appointment without notice, more than 15 minutes late for an appointment with notice, or do not arrive and fail to provide notice, Business Days ‘Monday-Thursday Office Hours: Start of Business Day: 9 am (USA Eastem time zone) End of Business Day: 1 pm (USA Eastem time zone) BNHC reserves the right to update and/or change Business Days and/or Office Hours at any time Itis the sole responsibility of the Client to stay infomed of any changes. The official and current Business Days and Office Hours are posted and always available and accessible in the right-hand column of the BNHC website footer (BioNexusHealth com). Arrive: A client must follow the instructions below to Ammive on time for the appointment type: ‘Virtual and Phone. Virtual Appointments: ™ = BNHC prefers Zoom (zoom.us). Zoom is available for several devices: desktop. tablet, and mobile. Zoom offers a test meeting: https:/izoom usttest. BNHC Zoom name is Bionexus Health USA. Tris the sole responsibility of the Client to ensure their technology works properly prior to the appointment (“Ready Technology”) and they are waiting for the meeting “host” to ‘aufive before their appointment time. Itis the Clieat’s responsibility co familiarize themselves with the BNHC virtual appointment methods. Resources were provided to Client in the Introduction Letter, below. and made available on the BNHC website ™ BNHC offers a helpful guide on the BNHC website (bionexushealth.com!z0om), BNHC in no way guarantees this information is up to date or coect. Direct all technical support questions to Zoom (support.zoom.us). Zoom offers instructive videos on their support age. @ Atleast 30 minutes before the appointment the Client must test Client’s technology for the appointment, including but not limited to installing Zoom on a Client device from Zoom’s download page (zoom us/supportidowaload) and testing all technical equipment, including speakers and microphone. Zoom offers a test meeting: https‘//zoom usitest. HM Atthe time of appointment confirmation, Client will receive the meeting invitation email with a link to attend the scheduled Zoom meeting. DO NOT LOSE THIS EMAIL. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 12|PageM Atleast 15 minutes before the appointment, Clieat should have Ready Technology and open the meeting invitation email from the BNHC office. Follow the instructions below to join the appointment: open the meeting invitation email and click the meeting link inside of it: M the link opens the Zoom meeting page for the zppointment. The Client will receive a message on screen to wait for the “host” (BNHC doctor); M thereis a text link that will allow Client to test speakers and microphone, please check technical equipment before the appointment begins; when the “host” (BNHC doctor) joins the appointment a new message appears on the screen asking the Client to join themeeting. Click the green join audio conference by computer (or whatever device you are on) button; if the Client's device asks to access the microphone or camera: confirm, yes, or allow. Phone Appointments: Mt is the sole responsibility of the Client to ensure Ready Technology before the appointment. The Client must be ready and answer the call from BNHC doctor to begin the ‘appointment on time. of Late Arri [ithe Client knows Client will arrive less than 15 minutes late, Client must verbally notify BNHC. The missed time will be counted towards the scheduled appointment duration and charged Eailure to. ™ If Client fails to arrive per the Antive section for any of the appointment types: Virtual or Phone, BNHC reserves the right to charge Client per the Clinic Fee Schedule and reschedule the appointment upon a new deposit. Change Request Adequate Notice for: any follow-up zppointment requires three (2) Business Days written notice before the appointment date. If canceled without reschedule; no refunds or exchanges on any deposit. appointment is not available. All initial appointments are non-refundable and non transferable to any changes, refunds, exchanges, transfers of payment, appointment, or person, All Change Requests received after the End of a Bi ‘business day. ess Day will be attributed to the next Failure to Meet Adequate Notice: m BNHC will charge the Client per Clinic Fee Schedule. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 13|PageNo-Show: Ifthe Client fails to Arrive as so defined for any scheduled appointment: Virtual and/or Phone, without cause or notice, BNHC will charge Client the No-Show Appointment fee as so defined in the Clinic Fee Schedule and the Client forfeits the Deposit. The appointment may be rescheduled upon a new deposit. Ifthe Client Amives for any scheduled Virtual or Phone appointment, experiences technical difficulties, and did not Ready Technology, BNHC will charge Client the No-Show Appointment fee as so defined in the Clinic Fee Schedule and the Client forfeits the Deposit. ‘The appointment may be rescheduled upon a new deposit How to Avoi Fees: Only a documented medical emergency or an act of God (ex. a natural disaster) releases Client from applicable fees. Client must provide BNHC with Adequate Notice to cancel or reschedule any appointment. Client must Artive for any virtual or phone appointment with Ready Technology for the appointment or provide BNHC with Notice of Late Arrival. If Client Anzives on time and experiences technical difficulties with Ready Technology, BNHC allows 2 grace-period for technical woubleshooting as described below: 1. The Client is solely responsible fortroubleshooting technical challenges and may attempt troubleshooting: a. the appointment may continue if the technical issues are resolved within 15 minutes after the start of the appointment: ‘b. the Client’s troubleshooting time becomes a pat of the total appointment time and charged. The appointment will conclude tits scheduled time: c. Otherwise, the appointment is considered a No-Show appointment, charged per the Clinic Fee Schedule, and rescheduled BNHC sends cancellation and reschedule confirmation messages. Ifthe Client does not receive 2 confimation message, send BNHC proof of Adequate Notice to avoid any fees per the Clinic Fee Schedule. 1. The Client should verify they received a cancellation confirmation message. 2. The Client should review current Business Days and Office Hours as described above to avoid confusion about BNHC Business Days and Office Hours. [SIGNATURE PAGE FOLLOWS] November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 14|PageCancellation, Reschedule, And No-Show Policy Signature Page By signing below, I, the Client, attest, and consent that I fully and completely agree, understand, and stipalate to any and all terms in the Cancellation, Reschedule, and No-Show Policy. Tf Adult Client, print name Hfminor client, print name: ‘Ifminor client, print name of Client's Guardian: Signature of Adult Client or Client's Guardian: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 13| PageCREDIT CARD AUTHORIZATION Itis the BioNexus Health Clinic, LLC (“BNHC”) policy to have one valid credit card on file to process payments for products and services (collectively. “services”), including, but not Timited to invoices for services rendered, incidentals, additional fees, and/or supplement orders to ‘keep the Client's account current. *FULL PAYMENT IS EXPECTED AT THE TIME OF SERVICES RENDERED* ‘The Adult Client or Client’s Guardian (collectively, “Client”) must provide BNHC witha valid credit card and/or drawn on bank debit card number (collectively, “Credit Card”) and required associated information needed to process a Credit Card. ‘The Credit Card must be in the Client's name or a signed pemission letter from the credit card holder (collectively, “Credit Card Holder") stating the Client has permission to use the Credit Card Holder's Credit Card for the BNHC Credit Card Authorization, in addition to the completed Credit Card Authorization. BNHC accepts all major bank issued cards that Square can process (Visa, MasterCard, ‘but CANNOT process nor accept payments from Health Savings Accounts (HSA) or spending accounts (FSA) cards, BNHCrequires 2 front and back copy of the Credit Card and a valid government-issued identification from the Credit Card Holder that matches the Credit Card. ‘The Credit Card must be valid for at least six months after the initial consultation. ‘The Credit Cardis protectedin accordance with Payment Card Industry (PCI) standards. I the Client and/or Credit Card Holder has read, understands, and agrees. (Inili@l itt @aeH Space) 1. Credit Card Holder will send a new BNHC Credit Authorization to BNHC when the available credit on the Credit Card is less than $1,000 and/or the Credit Card expiration date is less than 6 months. 2. Credit Card will be kept on file by BNHC and Credit Card Holder authorizes BNHC to ‘charge the Credit Card in the following events: a. Client approved invoices and any and all fees less than 30 days old. b. Client approved order, including but not limited to supplements. ¢. for any and all fees as set forth in any and all agreements by and between Client and BNHC to keep Client account current. for any andall attomey, collection, interest, and/or recovery fees incurred by BNHC for outstanding Client account balances older than 30 days. Client account balances outstanding over 30 days will accumulate interest at the highest rate allowed by law. e. if Client fails to Amive andlor give BNHC Adequate Notice, as so defined in the Cancellation, Reschedule, and No-Show Policy. Credit Card Holder will be charged the full ‘No-Show Appointment fee as so defined in the Clinic Fee Schedule. Tae Cancellation, November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 J0| PageReschedule, and No-Show Policy outlines how the Credit Card Holder can avoid the additional fees. 3. Credit Card Holder shall provide a front and back copy of a valid government-issued identification that matches the name on the Credit Card A. If Credit Card Holder is not Client, a permission letter as described above has been included and hereto annexured to this agreement. 5. BNHCreserves theright to charge a Convenience Fee as so defined in the Clinic Fee Schedule when BNHC processes a payment with the authorized Credit Card. Credit Card Number- Expiration Date: CVV Code: Associated Postal Code: Associated Country: ‘Name on the Card: By signing below, I, the Credit Card Holder, attest, and consent that fully and completely agree, ‘understand, and stipulate to any and all terms of the Credit Card Authorization. ‘Name of Client: Signature Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 I7|PageNOTICE OF PRIVACY PRACTICES HIPAA Privacy Statement ‘THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT THE ADULT CLIENT OR MINOR CLIENT AND/OR MINOR CLIENI’S GUARDIAN (COLLECTIVELY, “CLIENT,” “YOU.” OR“YOUR”) MAY BE USED AND DISCLOSED AND HOW CLIENT CAN GAIN ACCESS 10 THE INFORMATION FROM BIONEXUS HEALTH CLINIC, LLC (“BNHC,” “WE.” OR “OUR’). OUR COMMITMENT TO YOUR PRIVACY. BNHC understands that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our office or otherwise brought to our attention. Weneed this record to provide you with quality care andto comply with certain legal requirements. This notice applies toall of the records of your care generated by the staff and office personnel, USES AND DISCLOSURES TREATMENT: Your health information may be used by BNHC staff members or disclosed to ‘ther health care professionals for the purpose of evaluating your health, diagnosing medical, conditions, and providing weatment. For example, results of procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted ‘by BNC staff members. PAYMENT. Your health information may be used to seek payment from credit card companies that you may use to pay for services or if necessary infomation may be used for an outside collection agency to collect any balance due to us. For example, your credit card company may request and receive information on dates of service, the services provided, and the medical condition being treated HEALTH CARE OPERATIONS: Your health information may be used as necessary to support the day-to-day activities and management of BNH. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. LAW ENFORCEMENT. Your health information may be disclosed tolaw enforcement agencies to support government audits and inspections, to facilitate law enforcement investigations, and to comply with govemment-mandated reporting. APPOINTMENTS: Our practice may use and disclose your personal health information to ‘communicate with you about BNHC appointments. For example, we may need to contact you to schedule an appointment. OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: Disclosure of your health infomation or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information. you may submit a writtea revocation of the authorization. However. your November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 18| Pagedecision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization. ADDITIONAL USES OF INFORMATION: Your health information will be used by our staff to effectively communicate with you about products, services, and orders INFORMATION ABOUT TREATMENTS: Your health information may be used to send you information that you may find interesting on the treatment and management of your medical. condition. We may also send you information describing other health-related products and services that we believe may interest you. INDIVIDUAL RIGHTS: You have certain rights under the federal privacy standards. These include: HM theright to request sestrictions on the use and disclosure of your protected health information; Mi theright toreceive confidential communications conceming your medical condition and treatment; M theright to inspect and copy your protected health information; M theright to amend or submit corrections to your protected health information; M theright toreceive an accounting of how andto whom your protected health information has ‘been disclosed: 1M theright to receive a printed copy of this notice. DUTIES OF BNHC: We are required by law to maintain the privacy of your protected health information to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice. RIGHT TO REVISE PRIVACY PRACTICES: As permitted by law, we reserve theright to amend or modify our privacy policies and practices. These changes in our policies and practices ‘may be required by changes in federal and state laws and regulations. Upon request, we will provide vou with the most recently revised notice on anv office visit. The revised policies and practices will be applied to all protected health information we maintain. REQUESTS TO INSPECT PROTECTED HEALTH INFORMATION: You may generally inspect the protected health information that we maintain. Aspermitted by federal regulation, we require that requests for inspecting protected health information be submittedin writing. You ‘may obtain a form to request access to vour records by contacting BNHC. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request. COMPLAINTS: Ii you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concems to: BioNexus Health Clinic, LLC. 11 Burlington Drive. Suite 1A. Marlboro, NJ 07746 If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter descaibing the cause of your concem to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. EFFECTIVE DATE his notice was updated on and effective after July 16, 2020. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 19|PageACKNOWLEDGEMENT OF RECEIPTOF NOTICE OF PRIVACY PRACTICES. This document is to be signed by a person legally responsible for the Client's medical decisions relative to the treatment provided by BioNexus Health Clinic, LLC (“BNHC”). L (name of person legally responsible for Client's medical decisions, “Legal Decider”), hereby acknowledge that BNHC has provided Legal Decider with a copy of its Notice of Privacy Practices that describes how medical information about ("Client") may be used and disclosed, and how I can access this information. By signing below, I, the Legal Decider, attest, and consent that I fully and completely agree, ‘understand. and stipulate to any and all terms in the Acknowledgement of Receipt of Notice of Privacy Practices and the following: if Thave questions or complaints I may contact BNHC; Lam entitled toreceive updates upon request if BNHC amends or changes its Notice of Privacy Practices ina material way. Client, print name= Legal Decider, print name: Relationship of Legal Decider and Client: Signature of Legal Decider: Today's Date: SS ‘THIS SECTIONISTO BE COMPLETED BY BNKC, IF UNABLE TO OBTAIN WRITTEN ACKNOWLEDGMENT FROM LEGAL DECIDER. L (BNHC Staff Member), made a good faith effort to obtain a waitten acknowledgment of receipt ef the Acknowledgment of Receipt of Notice of Privacy Practices form the above-named Client and/or Legal Decider but was unable to because: [] Client and/or Legal Decider declined to sign this written acknowledgment document. [] Other (specify) = Signature and title of BNHC Staff Member Date November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 20\ PageCLINIC FEE SCHEDULE BioNexus Health Clinic. LLC (‘BNHC") is a fee for service practice and does not participate with any health care insurance plans. BNHC reserves the right to change the Clinic Fee Schedule. BNHC must provide the Adult Clieat or Client's Guardian (collectively, “Client”) with at least 90-day notification prior to the effective date. Any scheduled appointment at the time of notification will be exempt from any fees changes unless the appointment is rescheduled or considered No-Show as so definedin the Cancellation, Reschedule, and No-Show Policy. Service Fee USD$ Description Deposits: Non-refundable and non-transferable. Charged at time of booking. Applied to Consultation or Appointment Fee. M_UsA-based Initial Consultation _200 M_USA-based VIP Consultation __-450 1M USA-based Follow-up Appointment 50 International jal Consultation No Deposit _ Paid in full at time of booking. International Follow-up Appointments 100 Initial Concultatio 60 minutes M__Reguler (USA & International) 650 ne-time complimentary reschedule with 5 business days notice. _ VIP (USA & International) 950 Follow-Up Appointments: 45 minutes or less, depending on complexity. Non-refundable and Nom-transferable. See Follow-up Appointment Requirement of Introduction Letter about maintaining Client status. Virtual Appointment 350 Phone Appointment 350 ‘Other Appointment Fees: Non-refundable and Non-transferable. Allows you to aska few questions between 1 __15-Minute Consultation 100 follow up appointments Alter Office Hours ‘950/hour___By spacial appointment only. No Show Appointment Fullfee Full appointment fee charged. Email Foos: m_VIP Email Program 100/month _ Please ask for details. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 2I|PageAdditional Fees: D it Review Fee: $150 for other documents from previous years of illness. Documents within six months of the initial appointment are included in the initial appointment fee. Copy Fee: Pages 1 through 26 are 75 cents per pages, pages 27 through 99 are 50 cents per page, ‘and every page over 100 is 25 cents each. Convenience Fee: Up to 4% may be applied to any credit card processed by BNHC. Payment Types: Card payment types available through Square payment card processing (major credit cards and ‘bank-issued debit cards) and cash BioNexus Health cannot process nor accept payments from Health Savings Accounts HSA), flexible spending accounts (FSA) cards, Apple Pay, Android Pay, check, Bitcoin, or other ‘cayptocurrency. Additionally, BioNexus Health does not accept any payments through virtual processors such as ‘Venmo, Payoneer. and PayPal By signing below, I, the Client, attest, and consent that I fully and completely agree, understand, and stipulate to any and all terms in the Clinic Fee Schedule. Hf Adult Client, print name: Tfminor client, print name- Ifminor client, print name of Client's Guardian: Signature of Adult Client or Client’s Guardian: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 22|PageHEALTH SUMMARY Client Name Date of Birth DateofAppointment: ~—~—~—~—~—~—~—~—«dDate of First Symptom: Birthplace: "History of Tick Attachment. YES NO AlsoLivedI——~S~*~*~*~*””C”C”CSCSCistory of Bulls Eye Rash (Erythema Migrans): City&DatessSS~*~<“<*~=*~‘“‘*~*~*S*::::”CNt Se YES NO Citvy&Dats: ~~ —————S—~*~*~*~*~*S*«CLocation & Date: City& Dates: S*~*~<“«*~*‘“‘*‘«*‘W@ cation & Date City& Dates: ———S*~<“«~*‘“‘*‘C~L cation & Date: IF YOU NEED ADDITIONAL SPACE, PLEASE LABEL EACH ADDITIONAL ATTACHED PAGE. PART 1: Physicians Please list the doctors that Client saw and the reason: (begin with the most recent doctor) Doctor Address Date Seen Reason Seen wane 10 November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 23|PagePlease list the Client’s cuncent medications (pharmaceutical drugs) and supplements (vitamins, herbs, detox, etc.) including, dosages, who prescribed them, and how long Client has been taking them. If Clieat has been treated for Lyme disease in the past, please list antibiotics separately accurately and chronologically. “Medication Dosage How Often HowLong Prescribed by? 10 ul 12 B 4 1D 16 17 18 19 November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 24|PagePART 3: Chronological Case History ‘What is the main reason for your visit? November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 25|PagePART 4: Chronological Event History List event dates chronologically from birth forward (example: 6/89 Tick bite right side of neck; 9/95 childbirth... had flu-like symptoms.) ‘Typed entries are preferred. Many clients send in a typed medical summary. Give short summaries (2-3 lines) of each event. Date EventDoctor/Desctiption November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 20| PagePART 5: jetabolic Assessment Form Please list the 5 major health concems in your order of importance: 1 2 3 Check All That Apply ‘Symptom Within Last 2 Weeks | Over 1 Month Ago | Infrequently Fatigue Weakness. ‘Aches ‘Cramps Unusual Pain Tee pick Pain Headache Light Sensitivit Red Eyes, Blured Vision Tearing Sinus Cough, Shormess of Breath ‘Abdominal Pain Diarrhea Toint Pain ‘Moming Stiffness ‘Menory Focus/ Concentration Word Decreased Assimilation of New Knowledge Confusion Disorientation Skin Sensitivity “Mood Swings ‘Appetite Swings Sweats - especially night sweats November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 27\Page‘Temperature Regulation Excessive Thirst Tacreased Unination Static Shocks ‘Numbness Tingling Vertigo ‘Mecallic Taste ‘Tremors TOTAL November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 28|PageINFORMED CONSENT 1. L the Adult Client or minor Client’s Guardian (collectively. “Client”), am requesting admission into an education program and the self-application of the knowledge leamed fiom the ‘program conducted by BioNexus Health Clinic, LLC (‘BNHC”) and Jodie Dashore (“ID”) for the purpose of improving Client’s well-being and health. 2. The Client is aware that the BNHC program includes miscellaneous components, including, but not limited to, a self-health appraisal and/or history which may include a list of supplements taken, miscellancous testing which Imay deem necessary to provide infomation, ‘one-on-one consultations with JD and/or employees or agents of BNHC and education into the various health modalities available to improve Client’s health, including, but not limited to, diet, detoxification, supplementation and the latest technology for health renewal. It is the Client's “understanding that this program will assist Client in creating a personal, tailor-made protocol, and there will be follow-up education sessions after the initial program is disseminated. The Client is aware that each human body is different at all levels, including structurally and bio- chemically. and accordingly. each body will react differently tothe self-application. which will ‘be placed upon it. Accordingly. there is no certainty or predictability as to how a body might react to the miscellaneous knowledge which the Client intends to make use of in the improvement of their well-being and health. 3. The Client also is aware that underno circumstances will JD, under/or any emplovees cor agents of BNHC be engaging in diagnosis, treatment, operating and prescribing any human sease, pain, injury, nor are they licensed physicians suthorized by law to engage in such activities. 4. The Client is aware that under no circumstances is this program a substitute or alternative to proper medical care or supervision and agree that at all times during this program Client will take responsibility forbeing under the regular and continuous supervision of their ‘chosen docter. 5. Based upon an evaluation on the advisability of Client participation in the program in terms of personal history and physical condition and Client understand that Client will be ultimately responsible for their own health and well-being. Client chooses to participate in the program. 6. Client warrants and represents that Client has discussed intention to participate in this, ‘program with their physician and has described its various components to him/her, and Client ‘has obtained the pemnission and advice from their physician that their participation is notlikely to aggravate or activate any symptoms, illnesses, or disorders which Client may have, nor would it be harmful, injurious or detrimental to their health, safety or physical condition or well-being if Client so participate in the program. 7. Client acknowledges that Client is participating in this program of their own free will, and acknowledge that no effort has been made by JD or BNHC to encourage them to participate. ‘Nor has any claim, promise, or guarantee been made regarding the effectiveness, usefulness, performance or safety of the program. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 29\ Page8. Client acknowledges that Client has evaluated the advisability of participating in this ‘program, and Client accordingly agree that Client takes fall responsibility forthe physical, ‘mental, emotional transformations Client attain as a result of their participation. Client acknowledges and declares that the Client is voluntarily participating and in consideration of their consent to allow Client participation in the program. Client hereby agrees for themselves, their heirs, and assigns to hold JD, BNHC and any employees or agents thereof free of and ‘harmless from any and all liability arising out of Client participation in the program. The Client takes full responsibility for any and all injuries or losses, freely, knowingly, and vohmtarily agrees to assume all risks involved, if any, during the program. 9. Client agrees to cooperate and take an active role in their treatment by maintaining 2 positive attitude regarding treatment, continuing contact with and treatment fiom medical practitioners, and communicating progress and side effectsto the health care provider. Client ‘understands that Client is to continue all medication and other treatment modalities as they have ‘been prescribed unless otherwise directed by the doctor who prescribed them. 10. Client understands that there is no guarantee concerning the effect of the treatment. Client understands that Client is free to discontinue treatment at any time, but acknowledges that Client is responsible for full payment of the normal and necessary fees associated with screening and treatment. 11. Client acknowledges that Client has read the above paragraphs. Client fully ‘understands each and every paragraph, and Client freely and voluntarily agrees to abide by all of these conditions as evidenced by the Client’s signature below. If Adult Client, print name Ifminor client, print nam ‘Ifminor client, print name of Client's Guardian: Signature of Adult Client or Clients Guardian: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 30| PageEMAIL AND MESSAGING POLICY I. the Adult Client or Client’s Guardian (collectively. “Client”) understands that non- appointment access to BioNexus Health Clinic, LLC and/or Dr. Jodie A. Dashore (collectively, “BNHC’)is a rare privilege in today’s busy assembly line medical model, Email addresses and the client area (accessed fiom the login button on the top left of the BNHC website) are for current and active clients only. Use themessage centerin the client area as your primary contact point. The message center centralizes your needs and allows all staffto respond more efficiently. We understand that email feels more personal, and seems it will receive a more rapid response, but we assure you that sending an email delays all clinical responses. BioNexus Health is a boutique clinic witha small staff who handle a large number of curent and waiting list patients from over 50 countries. Ifthe scheduling staff asks you to ‘email paperwork or labs, please keep your reply to the request. The staff cannot respond to other questions and requests made via email. ‘When scheduling an appointment via the scheduling email address, please do not ask clinical questions. All clinical questions must go through the message center available in the dient area. The scheduling staff cannot relay clinical messages or questions. Everyone has an account to the client area with the email address they used to make their initial payment. Your usemame is the email address. If you are unable to login, try changing the password, and if that doesn't work it is okay to ask the scheduling staff for help. Navigating to the message center: after logging in, there are two ways to get to the message center. On thepost-login "Where to?" page click the pumple "go now" button under message center or, if you are in the client area, click on messages (near the center) in themain navigation menu, You will receive access after the initial appointment. ‘The client area offers several options, including frequently asked questions, request appointments. order supplements, send files. make payments. and more. You will receive access after the initial appointment. All consultations and correspondence, online or otherwise, are for educational purposes only. Dr. Jodie A. Dashore reviews every message to maintain the highest level of care. Do not reply to emails from noreply@bionexushealth.com. Replying to this email address sends the email into the trash and will be missed by BNHC. By choosing to communicate with BNHC, Client acknowledges and accepts: Mm Emails and messages are ONLY checked during normal business hours; W Clients may send ONE message through the message center per 24 hours: VIP clients do not have restriction on the number of messages allowed per dey: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 S1|PageAll emails and messages are answered in the order received; Wi Itmay take up to 36 hours for a reply to your email or message, not including non- ‘business days; All emails and messages should be very brief, and to the point so we may assist the maximum number of clients needing help. 1 We will NOT be able to respond to lengthy emails or messages. If you have a longer question, click "book appointment” in the client area main navigation mem to request a 15-minute consultation. Ifyou prefer email, BNHC offers 2 VIP email program. ™ PLEASE DO NOT SHARE ANY BNHC EMAIL ADDRESS with anyone, including doctors, friends, and family. If someone you know would like to become a patient, please tell them to use the website's request an appointment form available on the BNHC website. The online form is the fastest way to receive an appointment. By signing below, I, the Clieat, attest, and consent that I fully and completely agree, understand, and stipalate to any and all tems in the Email Policy. If Adult Client, print name: Ifminor client, print nam Ifminor client, print name of Clieat’s Guardian: Signature of Adult Client or Client's Guardian: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 52|PageTERMS OF SERVICE the Adult Client or Client’s Guardian (collectively, “Client”), has initialed to reaffirm the acceptance of the terms of cach Requested Materials agreement provided by the BioNexus Health Clinic, LLC (BNHC’). Iwas given, read, understood, completed, and. i Agreements’) required, signed (collectively, “Client __a. Introduction Letter: __b. Client Registration; ¢. Conseat To Release Confidential Information; d. Consent for Evaluation and Treatment; __e. Cancellation, Reschedule, and No-Show Policy; __£. HIPAA Privacy Statement; ___g. Acknowledgment of Receipt of Notice of Privacy Practices; __h. Email Policy: ___i. Credit Card Authorization; _j. Clinic Fee Schedule; ____k Health Summary 1. Supplement orders are not returnable, exchangeable, and/or non-refundable after ‘payment. a. Client will not begin treatment supplements until BNHC has reviewed the with Client in detail, and Client understands the purpose of each item on the supplement supplement list. bb. for any questions regarding supplements, including cost, I need to contact ‘one week of receiving the supplements. BNHC wit c. Dueto enormous volume, BNHC is only able to ship once per week 2. The Client may only email once per 24 hour period unless the Client is 2 member of the VIP program: otherwise, the Client will be charged per the Clinic Fee Schedule. a. The Clicat understands that emails need to be brief and it may take up to 48 ‘hours for BNHC torespond. 3. The Client understands that BNHC is not a primary care office nor an emergency medical office. All general medical issues or urgent care needs will be handled by the required ‘medical professional and not BNHC. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 33|Page4. The Client understands that if they experience a Jarisch—Herxheimer (“herxheimer” or jerxing”) reaction from the supplements, the Client needs to stop ALL supplements immediately and contact BNHC. 5. The Client understands that NO changes will be made to the coded invoice provided by BNHC, and BNHC cannot fax notes or speak with your insurance company. BNHC does offer any assistance with insurance providers, attomeys, or lawsuits. 6. All credit card alleged charging errors need to be discussed with BNHC before a ‘spute for any reason is made with Client's or the Credit Card Holder’s Credit Card company. ‘bank, or another dispute party. It is the client's responsibility if disputing a charge, please provide us with the exact date and time stamp along with the transaction ID of the alleged exroneous transaction. In the event the client should fail to follow any of these steps, BioNexus Health reserves the right to charge the client a $100 inconvenience fee as well as attomey fees if the dispute proceeds to legal counsel 7. To remain a current BNHC client, the Client must keep their account current and Anive at an appointment at least once in six months to remain an active Client. ‘If any term or provision of Client Agreements is found by a court of competent jurisdiction to be invalid, illegal or otherwise unenforceable. the same shall not affect the other terms or provisions hereof or the whole of the agreem ents, but such tem or provision shall be deemed modified to the extent necessary in the court’s opinion to render such term or provision enforceable, preserving to the fullest permissible extent the intent of Client Agreements herein set forth Any and all additional pages used by Client to add more information for any of the Client Agreements are thus annexured (added to)to its and this Agreement. Any dispute or controversy arising under or in connection with this Agreement shall be settled exclusively by arbitration, conducted before a panel of three arbitrators in Monmouth County, New Jersey, USA. in accordance with the tiles of the American Arbitration Association then in effect. Judgment may be entered on the arbitrator’ award in any court having jurisdiction; the expense of such arbitration shall be bome by the Client. All Client Agreements executed by Client hereto constitute the entire agreement between BNHC and Client, supersedes all prior agreements both written and verbal with respect to its subject matter. constitutes along with the documents referred to in this Agreement a complete and exclusive statement of the tems of the agreement, and may be executed in any number of ‘counterparts (a copy is as effective as the original), each of which shall be deemed an original butall of which shall constitute the same instrument. Any and all notices and/or updates by BNHC where the right is reserved. whether received. not received. and/or accepted by Client supersede. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 34|PageTerms Of Service Signature Page By signing below, I, the Client, attest, and consent that I fully and completely agree, understand, and stipulate to any and all terms in the Terms of Service. If Adult Client, print name: Ifminor client, print name: Ifminor client, print name of Client's Guardian: Signature of Adult Client or Client's Guardian: Today's Date: November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 33|PageONLINE CLIENT AREA Everyone has an account. You created an account during Initial Consultation checkout. After Your initial consultation. you will have access to the client areas, including the store and Message Center. How to Login Go to: https//bionexushealth.com (On the top leff, click the "Log In” button (gs seen below) resantaions Contac Us Emails f sowaateenrn Testimonials Events About [Request Appointment Enter your Email Address as the Usemame and Password, then click the "Log Me In” button. ‘Username: [email address used on checkout] Password: [password created on checkout] 8 an Becomes Member Boone @ BicNexus Health Rescurces Autism Camel Milk Lyme Mold @§ Recipes ¥ voreafenas Membership Log} Username or Email: Password signup nov forgot pasword? Remember Me TE you do not know your password, click the "forgot password?" link below the Password field Input your email address and click the "Get New Password” button. November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 30| Page‘Home - Where to? hutps:/member.bionexushealth.com/where-to/ After logging in, you will land on the "Where to?" page. We have added shortcuts on this page, to assist you. Click on the appropriate purple "Go Now" button. HOME Where to? oS 5 BR Message Center| Payment store Appt. ‘There are more options in the menus of the Client Area. Clicking on any of the "Go Now" buttons takes you to the Client Area. Client Area Menu ‘Contact Office Use the Message Center to contact the oflice. To get to the Message Center click on the purple "Go Now” button under Messages on the "Where to?" page or "Contact Office” in the menn of the Client Area near the center of the To start a message, click on the blue "New Message" bution in the main menu at the top of the page. Home Message Center Store Help¥ Appointment J ew Message | November 2021.02 BioNecus Heaith Clinic, LLC 11 Burmgton Drnve, Suite 14, Marlboro, NI 07740 37|Page