Specialist Coordination. The Clinic shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic physicians and medical staff. APPENDIX B PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM Monthly fees, as set out in Appendix C, shall apply to the following Patient(s): / / Printed Name of Member 1 Date of Birth (MM/DD/YYYY) Age Street Address City, State, Zip Home Phone Cell Phone (required) Preferred email (required) / / Printed Name of Member 2 Date of Birth (MM/DD/YYYY) Age Home Phone Cell Phone (required) Preferred email (required) Child/Children to Whom this Agreement Applies: / / Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) / / Age Printed Name Date of Birth (MM/DD/YYYY) Age Preferred Payment Method* □Yearly (Credit/Debit Card/Bank Draft) □Monthly (Credit/Debit Card/Bank Draft) *All patients must have a credit or debit card on file to cover the cost of membership and any incidentals not covered under the Agreement. I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. / / Signature of Member 1 Date / / Signature of Member 2 Date APPENDIX C FEE ITEMIZATION 0-18 years of age $20.00 per month* 19-55 years of age $60.00 per month 56+ years of age $80.00 per month Re Enrollment Fee $200.00 per person** *With the enrollment of at least one adult member, otherwise will be $60.00/month. **Non-refundable fee. Should your membership lapse or be terminated, the re enrollment fee must be paid for membership to become active. Re enrollment will be considered on a case by case basis. Name Fee Name Fee Name Fee Name Fee Name Fee Name Fee

Specialist Coordination. Clinic and Physician shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Clinic Physician. APPENDIX B FEE ITEMIZATION Standard Membership Fee 0-17 years of age: $20 per month (with the enrollment of at least one adult member) 18+ years of age: $70 per month Family Max: $180 per month DPC Plus Membership Fee (for select patients only) 18+ years of age: $250 per month One Time Registration Fee Individual: $50 Family max: $150 Discounts Options

Specialist Coordination. Practice and Physician shall coordinate as best as possible given the constraints in interoperability in the current healthcare system with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist’s fees or fees due to any medical professional other than the Practice Physician. Attachment F FEE SCHEDULE Membership Fee Adult: $80 per month Child: $80 per month without a member adult, or $40 per month with member parent/guardian* Couple: $150 per month Family: $225 per month** *Child rates apply through age 17. **Up to two dependent children. Each additional child $35/month. Re-enrollment fee: If a Patient discontinues membership and wishes to re-enroll in the Practice, the Practice reserves the right to decline re-enrollment or to require a Re-enrollment Fee equivalent to two months of membership. Additional Fees Cryotherapy of skin lesions, $15.00 (plus pathology fees, if applicable) Excision of lipoma/cyst/mole/skin tag/lesion, Simple aspiration/injection of joint, Wound repair and sutures, Abscess Incision and Drainage, IUD Removal Acupuncture: First session - free Auricular Acupuncture - free 20 minute session - $30 60 minute session - $80 Functional Medicine Consultation: First consultation free (up to 1.5 hours) $55 per 30 minute consult thereafter Labs: Cost plus 10%

Specialist Coordination. Your provider shall coordinate treatment and care with Your medical specialists and shall assist with specialist referrals as requested and/or necessary. Your Membership Agreement does not include or cover specialist's fees or fees from any medical professional outside of the practice. All such fees are the personal responsibility of the Member. APPENDIX B PATIENT ENROLLMENT FORM check yes where indicated only if you agree to text message communication. provide an email address only if you agree to email communication. your signature indicates acceptance of the terms of the patient agreement. The fees as set out in the attached Appendix C, shall apply to the following Patient(s), who by signing below (or as parent or legal guardian) certify that they have read, agree to, ad are bound by the terms and conditions of the Agreement. Patient 1 Print Patient Name_______________________________ Date of Birth___________ Street Address__________________________________________________________ City, State, Zip_____________________________________________________ Home Phone____________ Cell Phone ____________Email_______________ Agree to Text Communication: (check one below) Yes No Signature: _____________________________________________________________ Patient 2 Patient Name_______________________________ Date of Birth___________ Street Address__________________________________________________________ City, State, Zip_____________________________________________________ Home Phone____________ Cell Phone ____________Email_____________ Agree to Text Communication: (check one below) YES NO (check one) Signature _______________________________________________________________ MINORS TO WHOM THIS AGREEMENT APPLIES: PRINT NAME ______________________________________________________________ DATE OF BIRTH ________________________ MM DD YYYY PRINT NAME ______________________________________________________________ DATE OF BIRTH _________________________ MM DD YYYY PRINT NAME ______________________________________________________________ DATE OF BIRTH ______________________ MM DD YYYY ______________________________________________________________________________ DO YOU AGREE TO TEXT MESSAGE COMMUNICATION IN REGARD TO THE ABOVE-NAMED CHILDREN? (CHECK ONE) YES NO PARENT/GUARDIAN: SIGNATURE: _______________________________________________________________ PRINTED NAME: _______________________________________ DATE: ___________ REALTIONSHIP TO MINOR/S): ______________________________...

Specialist Coordination. CLINIC and Dentist shall coordinate with dental specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understand that fees paid under this Agreement do NOT include and do NOT cover specialist’s fees or fees due to any medical professional other than the CLINIC Dentist. APPENDIX B FEE ITEMIZATION - November 2023 Member: $30 per month DISCOUNTED RATES - November 2023 ● 2 Exams (D0150, D0120) discounted 100% for each 12 month subscription ● 2 Dental cleanings (D1110) discounted 100% for each 12 month subscription ● 1 Limited exam (D0140) discounted 100% for each 12 month subscription ● 2 Fluoride varnish (D1206) discounted 100% for each 12 month subscription ● Any necessary x ray (D0210, D0274, D0220, D0230) discounted 100% for each 12 month subscription ● All other Dental Services discounted 30% for each 12 month subscription DENTAL SAVINGS PLAN PATIENT ENROLLMENT FORM ● Membership fees as set out above shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the Carrollwood Village Dental Medical Retainer Agreement Form. ● All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement. ● I certify that I have read, understand, and agree to the terms set forth in Carrollwood Village Dental, Dental Agreement Form. I further certify that I have received a copy of this form. ● I understand that the Membership fee may be adjusted annually. ● A digital copy is available on our website under at xxxxx://xxx.xxxxxxxxxxxxxxxxxxxxxxxx.xxx/forms Printed name: Signature:

Specialist Coordination. The physician shall coordinate with the Patient's medical specialists and clinicians and shall assist the Patient in obtaining specialty care as needed. The Patient understands that fees paid under this Agreement do not include and do not cover specialist's fees or fees due to any medical professional other than the Practice physician. Appendix B PATIENT ENROLLMENT FORM THE FEES AS SET OUT IN THE ATTACHED APPENDIX C, SHALL APPLY TO THE FOLLOWING PATIENT(S). THE PARENT OR GUARDIAN, BY SIGNING THIS APPENDIX B, CERTIFIES THAT THEY HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF THIS AGREEMENT. CHILD/CHILDREN TO WHOM THIS AGREEMENT APPLIES: Patient Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Patient Patient Patient Patient Patient PARENT OR GUARDIAN: (Provide email address only if you agree to Email communication) Street Address City, State, Zip Preferred Contact Number: Cell Phone: Email: Check YES/NO where indicated only if you agree to text message communication. Your signature indicates acceptance of the terms of the Patient Agreement DO YOU AGREE TO TEXT AND EMAIL MESSAGE COMMUNICATION REGARDING THE HEALTH CARE CONCERNS OF THE ABOVE-NAMED CHILDREN? (CHECK ONE) ◻YES ◻NO Signature: Date: Printed Name: Relationship to Patient(s): Appendix C MEMBERSHIP ITEMIZATION Annual Membership Fee $5950 for children under 2 years old $4950 for children over 2 years old This includes all services listed in Appendix A as well as in-house labs and unlimited office visits, text messaging, video conferences and phone calls with 24/7 access to the providers. Discounts

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