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IMPORTANT: PLEASE READ THESE DIRECTIONS BEFORE COMPLETING THIS APPLICATION. THIS APPLICATION IS ALSO A REPAYMENT INSTALLMENT CREDIT SALE CONTRACT. IN ADDITION TO REPAYMENT AND EMPLOYMENT INFORMATION, BY HITTING SUBMIT, YOUR DEBIT OR CREDIT CARD WILL BE IMMEDIATELY CHARGED THE 3 MONTHS OF ADVANCED PAYMENTS AS SHOWN ABOVE. If you are applying for individual credit in your own name, are not married, and are not relying on alimony, child support or separate maintenance payments or on the income or assets of another person as the basis for repayment of the credit requested, complete all Sections other then the Co-Applicant/Other Person Section. In all other situations, complete all Sections, providing information in the Co-Applicant/Other Person Section about your spouse, a joint applicant, or the person on whose alimony, support or maintenance payments or income assets you are relying.

PATIENT / APPLICANT INFORMATION:

EMPLOYER INFORMATION:

Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation. Alimony, child support, separate maintenance received under:

RETAIL INSTALLMENT CREDIT SALE CONTRACT Credit Sale Contract. Notice to the Borrower and/or Co-Borrower. Do not sign this contract before you read it or if it contains any blank space. When you sign this contract, you are entitled to a copy of it that is filled in, every necessary respect. You should keep it. This contract is covered by your states’ credit sale law, and you have the rights of a Borrower and/or Co-Borrower under that law. Under the law, you have the right to pay off in advance the full amount due and under certain conditions to obtain a partial refund of the service charge. In those cases, the principal owed as of the date of payment, plus any balance to cover charges or interest accrued to that date, shall be canceled. Any holder of this consumer credit contract is subject to all claims and defenses which the Borrower and/or Co-Borrower could assert against the Creditor of goods or services obtained pursuant hereto or with the proceeds hereof, recovery hereunder by the Borrower and/or Co-Borrower shall not exceed the amount paid by the Borrower and/or Co-Borrower hereunder. You also may have rights under other state and federal laws. I/we have reviewed the Terms and Conditions of this agreement. I/we understand that I/we am/are responsible for payment of the Total Amount Owed, and agree to the Terms and Conditions of this Agreement. I have received a copy of Appendix A attached herein.

Furthermore, I agree that a staff member may submit this application on my behalf to CPU. I also agree that this application and any information I submitted with it may be forwarded to other creditors. By signing below, I further agree that such other creditors may obtain a credit report and rely on it making a credit decision. Governing Law. The validity, interpretation, and enforcement of this Agreement and its terms and conditions shall be interpreted and governed under the laws of the State of Colorado.

Please review the following Terms and Conditions prior to signing. No Interest Rate. At no time will any interest be charged to Borrower and/or Co-borrower. There is no Origination Fee or Monthly Servicing Fee. Late Fee. In the event that a payment due under this Agreement is not made within fifteen (15) days of the scheduled Payment Date, as set forth herein, the Borrower and/or Co-borrower shall pay a late fee in accordance to Appendix A attached hereto. You hereby agree to pay the appropriate late fee based upon the state requirements where you received your services. See Appendix A. Returned. Item Fee. In the event that a check or other form of payment is returned for insufficient funds, or for any other reason, PPN will charge the Borrower and/or Co-borrower a returned item fee in accordance with Appendix A attached hereto. You hereby agree to pay the appropriate returned item fee based upon the state requirements where you received your services. See Appendix A. Monthly Statements. Borrower and Co-borrower agree that they will not receive a monthly statement, payments will be made via automatic withdrawal from your bank account, debit card or credit card, and these withdrawals will appear on your bank, debit card or credit card statement. Written statements of your account balance can be provided upon written request. Changes to this agreement. No oral modifications will be effective or accepted. If there is a reduction to the amount owed under this Agreement, this will be made solely by notifying the patient of the reduction. If there is an increase to the amount owed under this Agreement, this will be made by obtaining the written consent of the patient and It may take as many as 5 days for such changes to take effect. While modifications are being processed, the Borrower and/or Co-Borrower will remain responsible for any charges under this Agreement. PPN reserves the right to accelerate the payment of the balance to the payable on demand. Notice to the Assignee. The assignee receiving or acquiring this retail installment contract or a promissory note related thereto shall be subject, under equal conditions, to any claim or defense that the Borrower and/or Co-Borrower may initiate against the Creditor. The assignee of the contract shall be entitled to file against the Creditor all the claims and defenses that the Borrower and/or Co-Borrower may raise against the Creditor of the goods and the services. No Prepayment Penalty. Borrower and/or Co-borrower understand that the obligations under this contract may be prepaid in whole or in part at any time, without premium or penalty. The amount you will be required to pay in order to prepay the contract will be equal to the Total Amount Owed set forth above less and amount equal to the number of full months of the contract terms that have not expired as of the date of prepayment multiplied by the Servicing Fee set forth above. Borrower and/or Co-borrower may contact CarePayUSA by calling 303-790-2300. Default by Borrower or Co-Borrower. The breach of any term of this Agreement by Borrower or Co-borrower, or the failure to make any payment in full or on a timely basis as required herein, shall constitute a default. Upon such default, the entire unpaid balance shall become immediately due and payable. Further, Borrower and Co-borrower agree to pay all costs and expenses incurred by CPU and/or as the result of such default, including costs and expenses of collection (including without limitation the costs of CPU servicing on behalf of named Provider and all reasonable attorneys’ fees. CPU or its assigns can furnish information concerning my account to consumer reporting agencies and others who may properly receive that information. APPENDIX A States can change NSF Fees & Late Fees- Please check with your local jurisdiction.