TCPA CLASS ACTION SETTLEMENT CLAIM FORM

1 Berdon Claims Administration LLC | Website: | Toll-Free Phone: (800) 766-3330 TCPA CLASS ACTION SETTLEMENT CLAIM form In order to receive benefits from this SETTLEMENT , you must provide all of the information below and sign this CLAIM form . Your CLAIM form must be postmarked on or before February 13, 2015. Late CLAIM forms will not be considered. I. CLAIMANT INFORMATION Claimant Name: _____ Mailing Address: _____ _____ _____ Telephone Number (Day): _____ E-mail Address: _____ Did you receive one or more text messages promoting the services of Swedish Medical or Universal Men s Clinic in February or March 2013 without your consent?

2 [ ] YES | [ ] NO If the answer is yes, provide the cellular telephone number at which such message(s) were received: _____ II. FREE BLOOD SCREENING VOUCHER If you are a member of the SETTLEMENT CLASS but do not wish to make a CLAIM in this matter, you are still eligible to receive a voucher for a free blood screening examination at any LabCorp facility. [ ] Yes, by checking here, I wish to receive a voucher for a free blood screening examination at any LabCorp facility. I understand the voucher will be in my name and sent to the address listed above, and also that additional fees may apply if I request services beyond the free screening. III. CERTIFICATION AND SIGNATURE By signing and submitting this CLAIM form , I certify that the information contained in the form is true and correct. SIGNATURE: _____ Date: _____ PRINT NAME: _____ IV.

3 SUBMISSION INSTRUCTIONS After completing this form , mail it to International Clinic Consultants TCPA Litigation SETTLEMENT , c/o Berdon Claims Administration LLC, Box 9014, Jericho, NY 11753-8914; or fax it to (516) 931-0810.