PATIENT CONSENT AND ACKNOWLEDGEMENT | WW USA

PATIENT CONSENT AND ACKNOWLEDGEMENT

By signing this Consent and Acknowledgement, I am authorizing my healthcare provider to submit my prescription hormone replacement therapy kit consisting of either (a) an estradiol patch alone or (b) an estradiol patch and progesterone pill (“HRT Kit”) to Carepoint Healthcare LLC, Inc. (“Carepoint Pharmacy”) for fulfillment and dispensing through its mail order facilities. I acknowledge that I have the right to have my prescription sent to a pharmacy of my choice and that I choose Carepoint Pharmacy as the dispensing pharmacy for my HRT Kits.

I understand that if I am enrolled in a commercial insurance program, or government sponsored healthcare program or public assistance programs (i.e., Medicare, Medicaid, TRICARE, etc.) (collectively, “Third Party Program”), I cannot utilize the benefits of such Third Party Programs in the purchase of HRT Kits. I understand that any cost I incur in purchasing HRT Kits through WW International will not count toward my out of pocket expense for such Third Party Program. I acknowledge and agree that I cannot and will not submit any claim regarding HRT Kits to any Third Party Program.