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 Wegovy to CenterWell Pharmacy, Inc. (“CenterWell 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 CenterWell Pharmacy as the dispensing pharmacy for Wegovy.

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 Wegovy. I understand that any cost I incur in purchasing Wegovy 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 Wegovy to any Third Party Program.