Consent Release

This document is intended to serve as confirmation of informed consent for an intramuscular injection provided by Dr. Seth Camhi, MD of Katalyst Wellness. As far as my knowledge, I am not allergic to any of the following, B12, L-Carnitine, Biotin or Glutathione. My signature below confirms that: 1. I understand the risks, benefits and potential side effects of intramuscular injections of water-based vitamins. 2. The procedure(s) has been adequately explained. 3. I have received all the information and explanation I desire pertaining to the procedure. 4. I authorize and consent to the procedure(s).

Social Media Release

Social Media Release We respect patient’s health privacy, and do not utilize any patient’s identifiable health information or images in our marketing without advance written patient consent. When patients elect to share personal information (including images of themselves) via social media or otherwise, Katalyst Wellness wants to ensure they do so fully informed on their decision. HIPAA and other state or federal privacy laws DO NOT prohibit patients from voluntarily electing to publicly share their health information and images. Sharing that health information and images constitutes a public disclosure of health information. There is no HIPAA or other data privacy protections attached to publicly shared information/images. Should patient wish to reference Katalyst Wellness in any self-published health information or image, Katalyst Wellness requests that the patient secure our advance written consent (as a means of protecting Katalyst Wellness’s trade name and other intellectual property rights). By signing the box below you are giving us this notification. Katalyst Wellness does not require patients or potential patients to sign this guidance as a condition of securing treatment but has communicated this information in the interest of protecting the privacy rights of patients, Katalyst Wellness, and other patients. Your signature confirms your receipt of this guidance.