Self-Pay Payment Agreement

Sculptd Minnesota, LLC d/b/a EVOLVD, EvolvdRx, and Evolvd Aesthetics
6906 153rd St W, Apple Valley, MN 55124
Contact: [email protected] | (952) 234-3239

Important Notice

EVOLVD operates on a self-pay basis only. EVOLVD does not accept insurance, Medicare, Medicaid, or other third-party payers. By accepting this Agreement, you acknowledge and agree to full financial responsibility for all services and products purchased.

Agreement Overview

This Self-Pay Payment Agreement (“Agreement”) is entered into between you (“you,” “your,” or “Client”) and Sculptd Minnesota, LLC d/b/a EVOLVD, EvolvdRx, and Evolvd Aesthetics (“EVOLVD,” “we,” “us,” or “our”).

By enrolling in services, submitting payment, or checking the acknowledgment box, you agree to the terms below.

1. Self-Pay Status

You understand and agree that:

All EVOLVD services are self-pay

EVOLVD does not bill insurance

EVOLVD does not submit claims on your behalf

Any amounts paid are not insurance premiums

You agree not to submit EVOLVD invoices to any insurance carrier, Medicare, Medicaid, HSA administrator (unless explicitly allowed), or other third-party payer unless otherwise directed in writing

2. Scope of Charges

You agree to pay for all applicable charges, which may include but are not limited to:

Non-medical aesthetic or wellness services

Telehealth administrative services

Provider review fees

Clinical program coordination

Laboratory coordination fees

Prescription coordination fees

Membership or subscription fees

Shipping and handling (if applicable)

Clinical services, including evaluation, diagnosis, and prescribing, are provided by independent licensed providers through an affiliated medical group. EVOLVD charges administrative and program fees related to coordination and support.

3. Payment Timing

You agree that:

Payment is due in full at the time of purchase or enrollment

Services will not be rendered until payment is received

Memberships and subscriptions authorize automatic recurring billing

Failure to maintain valid payment information may result in service interruption or cancellation

4. Non-Refundable Charges

You understand and agree that the following are strictly non-refundable, except where required by law or expressly approved in writing by EVOLVD:

Telehealth consultations or provider reviews

Laboratory tests once ordered or processed

Prescription medications once authorized, transmitted, or processed by a pharmacy

Shipping fees

Services already rendered

Missed or late-cancelled appointments

Administrative or program fees

5. Prescriptions & Pharmacy Fulfillment

You acknowledge that:

Prescriptions are issued solely at the discretion of licensed providers

Once a prescription is authorized and transmitted to a pharmacy, it cannot be refunded

Pharmacies operate independently and control compounding, processing, and shipping

Delays due to compounding standards, regulatory requirements, weather, or carrier issues are outside EVOLVD’s control

EVOLVD may assist with communication but does not guarantee pharmacy timelines.

6. Memberships & Subscriptions

If you enroll in a recurring program or subscription:

You authorize automatic billing at the disclosed frequency

Charges will recur until canceled in accordance with EVOLVD’s cancellation policy

Cancellations must be submitted at least five (5) days prior to the renewal date

Charges already processed are non-refundable

Prescriptions tied to a membership are non-refundable once authorized, even if cancellation is requested afterward

7. Chargebacks & Payment Disputes

You agree to contact EVOLVD at [email protected] prior to initiating a chargeback or payment dispute.

Improper chargebacks may result in:

Immediate suspension of services

Termination of memberships

Collections or recovery actions where permitted by law

8. Price Changes

EVOLVD reserves the right to:

Modify pricing, packages, or program structures

Introduce new fees or adjust existing fees

Apply changes prospectively

Price changes will not affect services already paid for unless required by law or disclosed at renewal.

9. Financial Responsibility Acknowledgment

You acknowledge that:

You are financially responsible for all charges incurred

You understand the services purchased and associated costs

You have had the opportunity to ask questions about pricing

You accept the risk that clinical eligibility or outcomes are not guaranteed

10. No Medical or Financial Guarantees

You understand that:

Payment does not guarantee medical approval, prescription issuance, or outcomes

Providers may deny, modify, or discontinue treatment at any time for clinical or safety reasons

No refunds are issued due to lack of clinical eligibility or treatment changes

11. Authorization to Charge Payment Method

By accepting this Agreement, you authorize EVOLVD and its payment processors to charge your selected payment method for:

One-time purchases

Recurring subscription charges

Authorized add-ons or upgrades

This authorization remains in effect until revoked in accordance with EVOLVD’s cancellation policy.

12. Limitation of Liability

To the fullest extent permitted by law, EVOLVD’s liability related to payment disputes or billing issues is limited to the amount you paid to EVOLVD in the twelve (12) months preceding the claim.

13. Governing Law

This Agreement is governed by the laws of the State of Minnesota, without regard to conflict-of-law principles.

14. Acknowledgment & Acceptance

By checking the box below or signing electronically, you acknowledge that:

You have read and understand this Self-Pay Payment Agreement

You understand EVOLVD is a self-pay provider

You accept full financial responsibility for all charges

You agree to the terms outlined above