Private Member Association Agreement Form Effective Date: December 26, 2025

This agreement explains your rights and responsibilities as a Private Member of Blue Pebble Health (BPH). By signing below, you choose to enter a private, member-only (non-public) relationship with the Private Member Association “PMA” and all its practitioners, staff and affiliates such as "Light Lounge."

1. What being a Private Member Means

Blue Pebble Health is a Private Member Wellness Association. It is not a public medical clinic. Membership creates a private contract that allows us to share natural wellness, functional health education, and lifestyle guidance in a private setting. All services and conversations occur privately within the Association.

This structure protects your right to receive natural health education and maintain more choices in your healthcare and our right to communicate freely and truthfully.

2. Important Disclaimer

Blue Pebble Health provides education, wellness guidance, lifestyle support, and functional-medicine–inspired root cause wellness information and wellness minded healthcare.

All materials, including supplements, protocols, programs, classes, handouts, labels, videos, and online content, have not been evaluated by the FDA and are not intended to diagnose, treat, cure, or prevent disease. The PMA does not necessarily follow what the conventional health system deems as ‘standard of care’ with regards to diagnosis and subsequent pharmacological treatments and surgery. Rather we believe the body has an innate capacity to heal given the right nutrition and wellness circumstances and employed in the right timeline. We believe in providing you with more options and wellness education as the best way to create the healing environment.

The PMA does not replace your public primary care provider or emergency care.

Some practitioners may hold professional licenses such as MD, DO, NP, PA, RN, MA, LEHP, or health coach. The type of service they provide depends on the nature of your visit, and their scope of practice. Licensed clinicians may offer medical support such as adjusting medications or ordering labs when appropriate, but this is provided privately under the PMA. Non-licensed practitioners and support staff may offer education only.

3. Member Services

All services occur within the private membership and examples may include but not limited to, wellness consultations, lifestyle and nutrition education, stress reduction, functional lab interpretation, repletion of nutrients, natural remedy and supplement education, Integrative and restorative therapies, private conventional medical care from licensed clinicians when needed. Access to member-only materials in the portal handouts.

4. Private Membership Status and Limits

By joining the BPH PMA, you agree that:

You are entering a private membership, not a public doctor-patient relationship.

All interactions, conversations, and materials are provided privately within this PMA.

You will not submit complaints, inquiries, or regulatory reports to state or federal agencies regarding services received within the PMA.

Any medical care, coaching and all other services provided are done privately under this agreement.

5. Membership Payments

Member contributions (as your visit fee or service fees) are paid at the time of the service and monthly subscription plans will be made available in the future.

6. Member Responsibilities

You agree to:

Provide accurate information

Use materials and recommendations responsibly

Maintain a public medical provider for emergencies and hospital care

Not share member-only materials outside the PMA

Understand that the focus of this Association is education and wellness support

Ask questions if you need clarity about services

7. Confidentiality

Your information is private and will not be shared outside the PMA except as needed for internal operations or with your written permission.

8. Cancellation and Termination

The Association may end membership for behavior inconsistent with PMA principles.

9. Binding Arbitration Agreement

All disputes or disagreements related to this membership or services received within the PMA will be resolved only through binding arbitration.

Arbitration replaces the right to sue in court or have a jury trial.

A neutral arbitrator will make the final decision.

Damages, if awarded, are limited to a maximum of $20,000.

Each party pays their own arbitrator fees.

The cost of the neutral arbitrator is shared unless the arbitrator decides otherwise.

Arbitration will take place in Utah under the Utah Uniform Arbitration Act.

You agree not to file lawsuits, malpractice claims, or licensing complaints for services provided within this PMA. Please see the arbitration agreement.

10. Agreement of Understanding

By signing this agreement, you confirm that:

You are voluntarily joining the Blue Pebble Health Private Member Association.

You understand that wellness education is the foundation of services offered.

You acknowledge that any medical support provided by licensed clinicians occurs privately under this PMA.

You agree to resolve any dispute only through private arbitration, waiving the right to involve public boards, agencies, or regulators regarding services received within the PMA.

Member Information

Name (full legal): ________________________________________

Address: _________________________________________________

City/State/Country: ________________________________________

Phone: ____________________________________________________

Member Signature: ____________________________________ Date: _______________

PHYSICIAN–PATIENT ARBITRATION AGREEMENT

Article 1: Required Written Information (Provided to Patient)
As required by Utah law (Utah Code Ann. § 78B-3-421), you are being provided the following information in writing before signing this agreement:

If you sign this agreement, any claim of medical malpractice (including negligence) must be resolved through binding arbitration instead of by a judge or jury in court.

In arbitration:
A neutral arbitrator (or panel of arbitrators) decides the case based on evidence presented.
Arbitrators are selected as follows: each party selects one arbitrator, and those two select a third neutral arbitrator from a list of individuals approved as arbitrators by Utah state or federal courts. If the two arbitrators cannot agree, either party may request a Utah court to select the third. Alternatively, if both parties agree, a single arbitrator may be used.

You may be responsible for certain arbitration-related costs, such as your share of arbitrator fees. Each party pays its own arbitrator and shares the cost of the neutral arbitrator unless otherwise ordered.

Signing this agreement is voluntary. Declining to sign will not affect your right to receive health care from this practice.

All parties waive the requirement to appear before a pre-litigation hearing panel under Utah Code Ann. § 78B-3-416.

The arbitration will be governed by the Utah Uniform Arbitration Act (Utah Code Ann. Title 78B, Chapter 11).

This agreement applies to claims arising from care provided by the practice, its physicians, nurse practitioners, physician assistants, employees, contractors, officers, agents, affiliates, and any entity through which the provider delivers services.

Claims subject to arbitration include, without limitation, claims for personal injury, wrongful death, emotional distress, loss of consortium, and punitive or exemplary damages, to the extent permitted by Utah law.

Per our Blue Pebble Health practice policies, the provider or staff has verbally encouraged you to read this information, read the agreement, and ask any questions before signing.

Article 2: Agreement to Arbitrate

Any dispute as to medical malpractice, including whether medical services rendered were unnecessary, unauthorized, improperly, negligently, or incompetently provided, will be determined by submission to binding arbitration as provided by Utah law, and not by a lawsuit or court process except as Utah law allows judicial review of arbitration proceedings.

Both parties, by entering into this agreement, give up their constitutional right to a court or jury trial for such disputes.

This agreement binds the patient and the health care provider, as well as third parties including heirs, spouses, children (born or unborn), family members, representatives, guardians, successors, assigns, and any person or entity claiming through or on behalf of the patient.

All claims for monetary damages related to diagnosis, treatment, or services, whether based in tort, contract, statute, or other legal theories, shall be resolved exclusively by binding arbitration.

For a pregnant patient, the term “patient” includes both the mother and her expected child or children.

This agreement also applies to any professional corporation, partnership, association, or business entity related to the provider, including employees and agents.

The parties agree that the total amount of damages that may be awarded in any arbitration under this agreement shall not exceed Twenty Thousand Dollars ($20,000), except to the extent Utah law requires a higher minimum amount.

Article 3: Initiation of Arbitration

A demand for arbitration must be in writing and delivered by certified mail to the other party.
The written demand shall identify the nature of the claim and the relief sought.

Each party shall appoint its arbitrator within 30 days of receiving the demand unless both parties agree to use a single arbitrator.

Either party may request that liability and damages be arbitrated separately, and the arbitrator shall grant that request.

Article 4: Applicable Law

Arbitration shall be governed by the Utah Uniform Arbitration Act.
Comparative fault principles under Utah law apply. Arbitration shall take place exclusively in Utah.

Each party shall select an arbitrator, and the two arbitrators shall select a neutral arbitrator. If they cannot agree within 30 days, either party may petition a Utah court to appoint the neutral arbitrator.

Each party pays its own arbitrator’s fees and shares equally in the cost of the neutral arbitrator unless otherwise ordered.

Arbitrators have the same immunity from civil liability as judges acting in a judicial capacity.

The parties consent to joinder or intervention of any person or entity who would be a proper additional party in a civil action. Any court action involving such parties shall be stayed pending arbitration.

Discovery shall be permitted under the Utah Rules of Civil Procedure. Either party may bring motions, including motions for summary judgment.

Article 5: Revocation / Rescission

You may rescind this agreement within 10 days of signing by delivering written notice by certified mail to the practice.
Revocation applies prospectively only and does not affect disputes arising before the rescission is received.

Article 6: General Provisions

Retroactive Effect: This agreement applies to all services rendered by the provider before and after signing. Its effective date is the date of the patient’s first medical service with the provider unless revoked.

Single Proceeding Requirement: All claims arising from the same incident, transaction, or related circumstances shall be arbitrated in a single proceeding.

Waiver of Untimely Claims: A claim is waived and forever barred if it would be time-barred under Utah law if filed in court, or if the claimant fails to pursue arbitration with reasonable diligence.

Article 7: Acknowledgment and Signatures

Patient Acknowledgment
I have received and read the required written information.
I understand that signing this agreement is voluntary.
I understand I am giving up the right to a court or jury trial for the claims described above.
I acknowledge that have been encouraged by the staff to read the agreement and ask questions.

Patient or Legal Representative Signature: __________________________ Date: __________
Print Name: ________________________________________________
If Representative, Relationship: _________________________________

Provider / Staff Acknowledgment
I confirm that the patient received the required written information before signing, was verbally encouraged to read the materials and ask questions, and was informed that signing is voluntary.

Provider/Staff Signature: ___________________________ Date: __________
Print Name: _______________________________________

This is provided for you to review the text before signing. Link to sign your forms electronically will be provided.