OPTIMIZEMD, LLC D/B/A DEXAFIT CINCINNATI AGREEMENT AND INFORMED CONSENT FOR DEXAFIT TESTING

OptimizeMD, LLC d/b/a DexaFit Cincinnati (“Practice”) and _________________________, (“Patient”) hereby enter into this this Agreement and Informed Consent for a Dexa Body Composition Scan (“Dexa”) Scan, a VO2 Max Cardiopulmonary Fitness Test (“VO2 Max”) test and Resting Metabolic Rate Test (“RMR”) test (“Agreement”) on the date indicated below.

What are the three (3) Core Tests Being Performed?

Dexa Body Composition Scan

DEXA is a dual-energy x-ray absorptiometry scan that is capable of measuring body composition. It is a fast, non-invasive procedure that uses low doses of x-rays to measure body composition. Although traditionally used to diagnose osteoporosis (using a segmental Dexa Scan), a Body Composition Scan is different. It will provide detailed insights into Patient’s body fat percentage, muscle mass, bone density and more. Dexa is a scientifically validated scan that, when operated correctly, has accuracy to within 2-3% of true values for fat mass, lean tissue mass, and bone mineral content. It is considered the gold-standard for body composition testing. Dexa goes beyond surface-level measurement

VO2 Max Cardiopulmonary Fitness Test

The VO2 Max test is a scientifically validated assessment designed to measure your body’s maximum capacity to utilize oxygen during exercise. It provides insights into your cardiovascular fitness by evaluating oxygen intake and carbon dioxide output while performing a graded exercise protocol. This non-invasive test is recognized as the gold standard for assessing aerobic capacity and endurance.

Resting Metabolic Rate (RMR) Test

The Resting Metabolic Rate (RMR) test is a non-invasive assessment that measures the number of calories your body burns at rest to sustain essential functions such as breathing, circulation, and digestion. This test involves analyzing your oxygen consumption and carbon dioxide production while you relax in a seated or reclined position. The results provide insights into your unique metabolic rate, forming the foundation for personalized nutrition and weight management plans.

Key Benefits of the Tests

Dexa Body Composition Scan

The Dexa Scan will provide Patient with a clear breakdown of fat mass, lean tissue mass, and bone mineral content for a complete picture of Patient’s body composition. By analyzing body composition, including fat distribution, it can help identify risks for conditions such as heart disease and diabetes. Measuring lean tissue mass enables detailed muscle analysis, providing key insights such as the Appendicular Lean Mass Index (ALMI), a metric closely linked to longevity and survival benefits. While not diagnostic for osteoporosis, the Dexa Body Composition Scan can provide a whole-body bone density estimate, providing the patient additional information to discuss with his or her healthcare provider.

VO2 Max Cardiopulmonary Fitness Test

The VO2 Max test offers personalized data that helps optimize your fitness, training, and overall health. It identifies your unique aerobic capacity, determines heart rate training zones, and evaluates your overall endurance. This information is valuable for tailoring exercise programs, improving athletic performance, and supporting long-term cardiovascular health and longevity. Risks of a VO2 Max Test.

Resting Metabolic Rate (RMR) Test

The RMR test provides critical data for creating effective and sustainable health strategies. It determines your daily caloric needs at rest, allowing for precise nutrition planning and tailored weight-loss, weight-maintenance, or performance diets. Understanding your RMR can help you avoid under-eating or over-eating, improve energy balance, and achieve long-term health goals.

Risks of the Tests

Dexa Body Composition Scan

The Dexa Scan involves radiation exposure which is significantly less than a person would receive from a standard chest X-ray or a dental X-ray. While the radiation exposure from a Dexa Scan is low, it is not recommended for pregnant women because even low doses of radiation can be harmful to an unborn child. Practice will not perform a Dexa Scan if Patient is pregnant or there is a possibility of pregnancy. Consequently, some Patients may be required to have a urine pregnancy test for confirmation. There are no risks associated with a urine test for pregnancy.

VO2 Max Cardiopulmonary Fitness Test

While the VO2 Max test is generally safe, it involves physical exertion and carries inherent risks, including abnormal blood pressure, fainting, irregular heart rhythms, or, in rare cases, more serious events such as heart attack or stroke. To ensure your safety, it is essential to report any unusual symptoms during the test. It is strongly recommended that you consult your physician before participating, especially if you have known medical conditions or concerns. It is always advised to discontinue the test voluntarily if you are feeling any concerning symptoms. An AED will be available at Practice’s location at all times.

Resting Metabolic Rate (RMR) Test

The RMR test is considered a safe and non-invasive procedure with minimal risks. Potential minor discomfort may arise from wearing a mask or mouthpiece during the test. Individuals with certain respiratory conditions may experience mild challenges, and it is recommended to consult with your physician before participating if you have any health concerns.

Preparing for the tests

Dexa Body Composition Scan

Prior to Patient’s appointment day for the Dexa Scan, Patient was told that a Dexa Scan will not be performed if Patient is pregnant or there is a possibility that Patient may be pregnant. Further, Patient was instructed that he or she should FAST for 2 hours prior to the scan, and should avoid exercise or other vigorous activity on the day of the exam. Patient was instructed to hydrate prior to the exam and not take any calcium or Tums in the 24 hours leading up to the exam. If Patient had a barium study; was injected with contrast for CT or MRI Scan; or had a Nuclear Medicine study, Patient was instructed to schedule his or her Dexa Scan appointment at least 7 days later. Patient was also instructed that he or she should wear tights, sports bra, compression shorts or other athletic attire without metal buttons, snaps, zippers or bra clasps. Patient also instructed to refrain from any clothing or undergarments that contain metallic imprinting inks or threads and to wear socks. Patient was instructed that they will need to empty pockets and remove metal items like watches, belts, glasses, and jewelry.

VO2 Max Cardiopulmonary Fitness Test

To achieve accurate results, it is important to prepare for the VO2 Max test. Avoid strenuous exercise, caffeine, supplements or stimulants and large meals for at least 3 hours before your appointment. Avoid alcohol for at least 12 hours prior to testing. It is OK to take your prescription medication the day of the test. Avoid exercise or any other vigorous activity for at least 12 hours prior to testing. Wear comfortable clothing and shoes suitable for exercise. Please inform the staff of any medical conditions, medications, or recent injuries that could affect your performance.

Resting Metabolic Rate (RMR) Test

To ensure accurate results, avoid eating or drinking anything other than water for at least 4 hours prior to your appointment, and preferably 8 hours. Patient should refrain from exercising for at least 12 hours beforehand, and avoid caffeine, nicotine, and alcohol during this period. Patient should wear comfortable clothing, but business attire is acceptable for this test as Patient will be relaxing in a chair. Patient is to inform the staff of any medical conditions or recent changes in health.

What to Expect During Your Tests

Dexa Body Composition Scan

The Dexa scan is a straightforward, painless, and non-invasive procedure. Patient will be asked to lie still on his or her back on an open-air DEXA scan table for approximately 10 minutes while the scanner does its work making a soft humming noise. The technologist administering the Dexa Scan will try to make Patient as comfortable as possible. Due to the extremely low radiation dose, the technologist will remain in the room. After the scan, Patient will receive a comprehensive report.

VO2 Max Cardiopulmonary Fitness Test

During the test, you will perform a graded exercise protocol on a treadmill or stationary bike while wearing a mask to measure oxygen and carbon dioxide exchange. The intensity will gradually increase until you reach your maximum capacity or choose to stop. Your heart rate and breathing will be continuously monitored, and you may stop the test at any time if you feel discomfort or fatigue. Valuable insights can still be obtained from a sub-maximal VO2 Max test, so it’s important to listen to your body and stop if you feel the need to shorten the test.

Resting Metabolic Rate (RMR) Test

During the RMR test, Patient will sit or recline in a comfortable position while wearing a mask or mouthpiece connected to the metabolic analyzer. You will breathe normally for approximately 10-20 minutes as the system measures your oxygen consumption and carbon dioxide output. The process is quiet and relaxing, requiring no physical effort on your part.

Detailed Report and Personalized Consultation

After the tests, Patient will receive a detailed report with actionable insights into his or her body composition, including fat mass and distribution, muscle mass and distribution, a total body bone mineral composition analysis, and additional calculated insights including visceral adiposity tissue (VAT) mass and Appendicular Lean Mass Index (ALMI calculation), as well as his or her aerobic capacity, heart rate training zones, and other key fitness metrics. The report also will outline your resting metabolic rate and caloric requirements. This report may include additional metrics, such as your respiratory quotient (RQ), to assess how your body utilizes fat and carbohydrates for energy. A brief personalized discussion will occur after the tests with Practice staff to help understand the report making it easier for you to apply results to your health, nutrition and fitness goals. If Patient would like for Practice’s physician Dr. DeMarco to provide a personalized consultation to help interpret the data, identify potential health risks, and create a plan to optimize your fitness and wellness, Patient agrees to engage Practice to do so by signing an agreement for further services and pay the required associated fees for those further services.

Fees for Testing

Patient paid the Practice a non-refundable fee when scheduling their appointment. Promotional discounts may be available but are not guaranteed. At the time of Patient’s appointment, he or she shall sign this Agreement and any other required documents such as the Notice of Privacy Practices. The non-refundable fee is for the tests, written report (printed and/or digital PDF copy) of the result of the tests. It does not include any personalized consultation by Practice’s physician or AI-enhanced upgrades.

No Insurance or Government-Funded Healthcare Plans

Patient is responsible for payment to Practice for the tests. Practice shall not bill any third-parties, insurance companies or government-funded healthcare programs, such as Medicare, Tricare, Medicaid or Indian Health Services, etc. If Patient is a beneficiary of any government-funded healthcare program such as those previously listed, Patient shall inform Practice of this fact. Practice may refuse to provide a test to Patient if Practice determines the tests are a covered service under Patient’s government-funded healthcare program as Practice is legally barred from accepting payment from a beneficiary of government-funded healthcare plans.

No Physician-Patient Relationship

The services provided under this Agreement do not: 1) establish a provider-patient relationship beyond the testing service provided to Patient herein; 2) obligate Practice and its physician to provide additional or further follow-up care beyond the testing service provided herein; or 3) create any obligation to order or refer Patient for further exams, test, or specialty care. Patient agrees to be responsible for contacting his or her regular healthcare provider to obtain appropriate follow-up care or to address any questions or conditions that may arise. Patient understands that if he or she wants to continue to be treated by Practice and its physician, Patient shall enter into further agreement(s) for services and pay the associated fees for those services.

General Terms

This Agreement, once signed by Patient, constitutes the entire understanding between Patient and Practice Patient specifically acknowledges that, by Practice’s offer and Patient’s acceptance of this Agreement, each is relying solely upon the representations and agreements contained in this Agreement and no others. All prior representations or agreements, whether written or oral, not expressly incorporated herein, are superseded and of no force or effect. Any dispute regarding this Agreement shall be resolved first by mediation conducted in accordance with the Commercial Arbitration Rules and Mediation Procedures of the American Arbitration Association (“AAA”). Each Party shall bear its own costs of mediation and one-half of the mediator’s and/or AAA’s fees. If the dispute is not resolved by mediation, the matter shall be settled by final and binding arbitration before a single arbitrator in accordance with the rules of the applicable dispute resolution organization. Any award by an arbitrator shall not include punitive or exemplary damages. This Agreement and the rights and obligations herein shall be construed and enforced pursuant to the laws of the State of Ohio. Patient irrevocably submit to the exclusive jurisdiction of the state and county courts located in Hamilton County and agree that all proceedings may be brought in such courts. YOU ACKNOWLEDGE AND AGREE THAT ANY CONTROVERSY WHICH MAY ARISE UNDER THIS AGREEMENT IS LIKELY TO INVOLVE COMPLICATED AND DIFFICULT ISSUES, AND THEREFORE, HEREBY IRREVOCABLY AND UNCONDITIONALLY WAIVE ANY RIGHT TO A TRIAL BY JURY IN RESPECT OF ANY LITIGATION DIRECTLY OR INDIRECTLY ARISING OUT OF OR RELATING TO THESE TERMS AND CONDITIONS OR THE TRANSACTIONS CONTEMPLATED HEREBY OR THEREBY.

OPTIMIZEMD, LLC

___________________________________________

David J. DeMarco, MD

PATIENT

______________________________________ date: ______

If Patient is a minor, then name and signature of parent or legal guardian