Document:

EX-4.4

 Exhibit 4.4 
 Form of Subordinated Note 
 (FACE OF SECURITY)

 [Each Global Security shall bear substantially the following legend: 
 UNLESS AND UNTIL IT IS EXCHANGED IN WHOLE OR IN PART FOR SECURITIES IN DEFINITIVE REGISTERED FORM, THIS SECURITY MAY NOT BE TRANSFERRED EXCEPT AS A WHOLE BY THE DEPOSITARY TO A NOMINEE OF THE DEPOSITARY
OR BY A NOMINEE OF THE DEPOSITARY TO THE DEPOSITARY OR ANOTHER NOMINEE OF THE DEPOSITARY OR BY THE DEPOSITARY OR ANY SUCH NOMINEE TO A SUCCESSOR DEPOSITARY OR A NOMINEE OF SUCH SUCCESSOR DEPOSITARY. UNLESS THIS SECURITY IS PRESENTED BY AN AUTHORIZED
REPRESENTATIVE OF THE DEPOSITORY TRUST COMPANY, A NEW YORK CORPORATION (“DTC”), TO THE ISSUER OR ITS AGENT FOR REGISTRATION OF TRANSFER, EXCHANGE OR PAYMENT, AND ANY SECURITY ISSUED IS REGISTERED IN THE NAME OF CEDE & CO. OR IN
SUCH OTHER NAME AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF DTC (AND ANY PAYMENT IS MADE TO CEDE & CO. OR TO SUCH OTHER ENTITY AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF DTC), ANY TRANSFER, PLEDGE OR OTHER USE HEREOF FOR
VALUE OR OTHERWISE BY OR TO ANY PERSON IS WRONGFUL INASMUCH AS THE REGISTERED OWNER HEREOF, CEDE & CO., HAS AN INTEREST HEREIN.] 

[If the Security has original issue discount for U.S. federal income tax purposes, insert tax legend: 

[FOR PURPOSES OF SECTIONS 1272 , 1273, and 1275 OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED (“THE CODE”), THIS
SECURITY IS BEING ISSUED WITH ORIGINAL ISSUE DISCOUNT. THE AMOUNT OF ORIGINAL ISSUE DISCOUNT (AS DEFINED IN SECTION 1273(A)(1) OF THE CODE AND TREASURY REGULATION SECTION 1.1273-1(A)) WITH RESPECT TO THIS SECURITY IS ______, THE ISSUE DATE
(AS DEFINED IN SECTION 1275(A)(2) OF THE CODE AND TREASURY REGULATION SECTION 1.1273-2(A)(2)) OF THIS SECURITY IS _______, THE ISSUE PRICE (AS DEFINED IN SECTION 1273(B) OF THE CODE AND TREASURY REGULATION SECTION 1.1273-2(A)) OF THIS SECURITY IS
_______, AND THE YIELD TO MATURITY (AS DEFINED IN TREASURY REGULATION SECTION 1.1272-1(B)) OF THIS SECURITY IS _______.]] 

 IDENIX PHARMACEUTICALS, INC. 

[ Title of Security ] 
  

			
	 No.
[                    ]
	 	CUSIP No.: [                ]
		 	[Common Code][ISIN]: [             ]
		 	[$                    ]

 Idenix Pharmaceuticals, Inc., a Delaware corporation (“Issuer”, which term includes any
successor corporation), for value received promises to pay to [If the Security is a Global Security — CEDE & CO.][If the Security is not a Global Security —
                                ] or registered assigns, the principal sum of
                     on
                ,             (the “Maturity Date”) [If the Security is to bear
interest prior to maturity, insert—, and to pay interest thereon from                      or from the most recent interest payment
date to which interest has been paid or duly provided for, [semiannually in arrears on                  and
                 in each year], commencing
                    ,              (each, an “Interest Payment
Date”) at the rate of [        % per annum], until the principal hereof is paid or made available for payment [If applicable insert—, and (to the extent that the payment of such
interest shall be legally enforceable) at the rate of         % per annum on any overdue principal and on any overdue installment of interest]. The interest so payable, and punctually paid or duly
provided for, on any Interest Payment Date will, as provided in the Indenture (as defined below), be paid to the Holder in whose name this Security (or one or more predecessor Securities) is registered at the close of business on the record date for
such interest, which shall be the                      or
                     (whether or not a Business Day), as the case may be, next preceding such Interest Payment Date (each, an “Interest
Record Date”). Interest will be computed on the basis of [a 360-day year of twelve 30-day months].] 

[If the Security is not to bear interest prior to maturity, insert—The principal of this Security shall not bear interest
except in the case of a default in payment of principal upon acceleration, upon redemption or at maturity and, in each such case, the overdue principal of this Security shall bear interest at the rate of
        % per annum (to the extent that the payment of such interest shall be legally enforceable), which shall accrue from the date of such default in payment to the date payment of such principal has
been made or duly provided for. Interest on any overdue principal shall be payable on demand.] 
 Reference is made to the
further provisions set forth on the reverse of this Security contained herein, which will for all purposes have the same effect as if set forth at this place. 

 IN WITNESS WHEREOF, the Issuer has caused this Security to be signed manually or by
facsimile by its duly authorized officer under its corporate seal. 
  

					
	IDENIX PHARMACEUTICALS, INC.
			
	By:	 	 	 	 
		 	Name:	 	 
		 	Title:	 	 

  

					
	Attest:
			
	By:	 	 	 	 
	Name:	 	 	 	 
	Title:	 	 	 	 

 This is one of the Securities of the series designated herein and referred to in the within-mentioned
Indenture. 
 Dated: [            ] 

 

					
	                           
         , as Trustee
			
	By:	 	 	 	 
		 	Title:	 	 

  

 (REVERSE OF SECURITY) 

IDENIX PHARMACEUTICALS, INC. 
 [ Title of Security ] 
 1. Indenture 

This Security is one of a duly authorized issue of debentures, notes or other evidence of indebtedness (hereinafter called the
“Securities”) of the Issuer of the series hereinafter specified, which series is initially limited in aggregate principal amount to
[$]                            , all of such Securities issued and to be issued under an
Indenture dated as of                     ,
                     (the “Indenture”) between the Issuer and
                                 as trustee (the “Trustee”). Capitalized
terms herein are used as defined in the Indenture unless otherwise indicated. The terms of the Securities include those stated in the Indenture and those made part of the Indenture by reference to the Trust Indenture Act of 1939, as in effect on the
date of the Indenture. The Securities are subject to all such terms, and Holders are referred to the Indenture and the Trust Indenture Act for a statement of all such terms. To the extent permitted by applicable law, in the event of any
inconsistency between the terms of this Security and the terms of the Indenture, the terms of the Indenture shall control. 

This Security is one of a series of Securities designated pursuant to the Indenture [and an [Supplemental Indenture] dated
            ,             , issued pursuant to Section 2.01 and Section 2.03 thereof (the
“Supplement”)] as                     . The Securities are general unsecured obligations of the Issuer. The Issuer may, subject to
the provisions of the Indenture and applicable law, issue additional Securities of any series under the Indenture. 
 2. Method of Payment.

 The Issuer shall pay interest on the Securities (except defaulted interest) to the persons who are the registered Holders at
the close of business on the Interest Record Date immediately preceding the Interest Payment Date notwithstanding any transfer or exchange of such Security subsequent to such Interest Record Date and prior to such Interest Payment Date. Holders must
surrender Securities to the Trustee to collect principal payments. The Issuer shall pay Principal and interest in money of [the United States] that at the time of payment is legal tender for payment of public and private debts. [However, the
payments of interest, and any portion of the Principal (other than interest payable at maturity or on any redemption or repayment date or the final payment of Principal) shall be made by the Paying Agent, upon receipt from the Issuer of immediately
available funds by                      [a./p.m.], New York City time (or such other time as may be agreed to between the Issuer and
the Paying Agent or the Issuer), directly to a Holder (by Federal funds wire transfer or otherwise) if the Holder has delivered written instructions to the Trustee 15 days prior to such payment date requesting that such payment will be so made and
designating the bank account to which such payments shall be so made and in the case of payments of Principal surrenders the same to the Trustee in exchange for a Security or Securities aggregating the same principal amount as the unredeemed
principal amount of the Securities surrendered.] 
 3. Redemption. 
 [The Securities of this series may be redeemed at any time [on or after                 ,
                ], as a whole or in part, at the option of the Issuer, upon mailing notice of such redemption not less than 30 and not more than 60 days to
the Holders of such Securities, at a redemption price equal to                     .] 

 4. Paying Agent and Security Registrar 

Initially, the Trustee will act as Paying Agent and Security Registrar. The Issuer may change any Paying Agent or Security Registrar
without notice to the Holders. 
 5. Denominations; Transfer; Exchange. 
 The Securities are in registered form, without coupons, in denominations of [$1,000] and multiples of [$1,000]. A Holder shall register the transfer of or exchange Securities in accordance
with the Indenture. The Issuer may require a Holder, among other things, to furnish appropriate endorsements and transfer documents and to pay certain transfer taxes or similar governmental charges payable in connection therewith as permitted by the
Indenture. [The Issuer need not register the transfer of or exchange (a) any Securities for a period of fifteen (15) days preceding the first mailing of notice that such Securities are to be redeemed, or (b) any Securities
selected, called or being called for redemption in whole or in part, except, in the case of any Security to be redeemed in part, the portion thereof not to be so redeemed.] 
 6. Persons Deemed Owners. 
 The registered Holder of a Security shall be treated as
the owner of it for all purposes. 
 7. Unclaimed Funds. 
 If funds for the payment of principal or interest remain unclaimed for two years, the Trustee and the Paying Agent will repay the funds to the Issuer. After that, all liability of the Trustee and such
Paying Agent with respect to such funds shall cease. 
 8. Defeasance. 
 The Indenture [as amended by the Supplement] contains provisions for defeasance at any time of (a) the entire indebtedness of the Issuer on this Security and (b) certain restrictive
covenants and the related Events of Default, upon compliance by the Issuer with certain conditions set forth therein, which provisions [apply] to this Security. 
 9. Amendment; Supplement; Waiver. 
 Subject to certain exceptions, the Securities
of this series, [the Supplement] and the provisions of the Indenture relating to the Securities of this series may be amended or supplemented with the written consent of the Holders of at least a majority in aggregate principal amount of the
Securities of this series then outstanding, and any existing Default or Event of Default, other than the non-payment of the principal amount of or interest on the Securities of this series, or compliance with
certain provisions may be waived with the consent of the Holders of a majority in aggregate principal amount of all the Securities of this series, then outstanding. Without notice to or consent of any Holder, the parties thereto may amend or
supplement the Indenture and the Securities to, among other things, cure any ambiguity, defect or inconsistency, provide for uncertificated Securities in addition to or in place of certificated Securities, or make any other change that does not
adversely affect the rights of any Holder of a Security. 
 10. Defaults and Remedies. 

If an Event of Default (other than certain bankruptcy Events of Default with respect to the Issuer) occurs and is continuing, the Trustee
or the Holders of at least 25% in aggregate principal amount of Securities of this series then outstanding (voting as a separate class) by notice in writing to the Issuer (and also to the Trustee if such notice is given by the Holders) may declare
[the entire principal] of the Securities of this series and the interest accrued thereon, if any, to be due and payable immediately in the manner and with the effect provided in the Indenture. If a bankruptcy Event of Default with respect to
the Issuer occurs and is continuing, then [the entire principal] of the Securities then outstanding and interest accrued thereon, if any, shall become due and payable immediately in the manner and with the effect provided in the
Indenture. Holders of Securities may not enforce the Indenture or the Securities except as provided in the Indenture. The Trustee is not obligated to enforce the Indenture or the Securities unless it has received indemnity satisfactory to it.
The Indenture permits, subject to certain limitations therein provided, Holders of a majority in aggregate principal amount of the Securities then outstanding to direct the Trustee in its exercise of any trust or power. The Trustee may withhold from
Holders of Securities notice of certain continuing Defaults or Events of Default if it determines that withholding notice is in their interest. 

  
 5 

 11. Subordination. 
 Reference is made to the Indenture, including, without limitation, provisions subordinating the payment of principal of and premium, if any, and interest on the Securities to the prior payment in full of
all Senior Indebtedness as defined in the Indenture. Such further provisions shall for all purposes have the same effect as though fully set forth at this place. 
 12. Trustee Dealings with Issuer. 
 The Trustee under the Indenture, in its
individual or any other capacity, may become the owner or pledgee of Securities and may otherwise deal with the Issuer as if it were not the Trustee. 
 13. No Recourse Against Others. 
 No stockholder, director, officer, employee or
incorporator, past, present or future as such, of the Issuer or any predecessor or successor corporation thereof shall have any liability for any obligation under the Securities or the Indenture or for any claim based on, in respect of or by reason
of, such obligations or their creation. Each Holder of a Security by accepting a Security waives and releases all such liability. The waiver and release are part of the consideration for the issuance of the Securities. 

14. Authentication. 
 This
Security shall not be valid until the Trustee manually signs the certificate of authentication on this Security. 
 15. Abbreviations and
Defined Terms. 
 Customary abbreviations may be used in the name of a Holder of a Security or an assignee, such as: TEN COM (=
tenants in common), TEN ENT (= tenants by the entireties), JT TEN (= joint tenants with right of survivorship and not as tenants in common), CUST (= Custodian), and U/G/M/A (= Uniform Gifts to Minors Act). 

16. CUSIP Numbers. 
 Pursuant to
a recommendation promulgated by the Committee on Uniform Security Identification Procedures, the Issuer has caused CUSIP numbers to be printed on the Securities as a convenience to the Holders of the Securities. No representation is made as to the
accuracy of such numbers as printed on the Securities and reliance may be placed only on the other identification numbers printed hereon. 
 17.
Governing Law. 
 The laws of the State of New York shall govern the Indenture and this Security thereof, and for all purposes
this Security shall be governed by and construed in accordance with the laws of such State without regard to any principle of conflict of laws that would require or permit the application of the laws of any other jurisdiction, except as may
otherwise be required by mandatory provisions of law. 

  
 6 

 ASSIGNMENT FORM 
 I or we assign and transfer this Security to 
  

	
	 (Print or type name, address and zip code of assignee or
transferee)

  

	
	 (Insert Social Security or other identifying number of
assignee or transferee)

	

 and irrevocably appoint
                                         
                                         
   agent to transfer this Security on the books of the Issuer. The agent may substitute another to act for him. 
  

							
	 Dated:
	 	 	  	Signed:	  	 
		 		  		  	(Signed exactly as name appears on the other side of this Security)

  

							
	 Signature
	 	 	  		  	
		 		  		  	
	 Guarantee:
	 	 	  		  	
		 	Participant in a recognized Signature Guarantee Medallion Program (or other signature guarantor program reasonably acceptable to the Trustee)

  
 7EX-10.1

 Exhibit 10.1 

EXECUTION VERSION 

AMENDMENT NO. 3 TO CREDIT AGREEMENT 

This AMENDMENT NO. 3 TO CREDIT AGREEMENT (this “Amendment”) dated as of February 25, 2014 (the “Amendment
No. 3 Effective Date”), among USMD HOLDINGS, INC., a Delaware corporation “Holdings”), UROLOGY ASSOCIATES OF NORTH TEXAS, P.L.L.C., Texas limited liability partnership, USMD INC., a Texas corporation, IMPEL MANAGEMENT
SERVICES, L.L.C., a Texas limited liability company, IMPEL CONSULTING EXPERTS, L.L.C., a Texas limited liability company, MAT-RX DEVELOPMENT, L.L.C., a Texas limited liability company, USMD OF ARLINGTON GP, L.L.C., a Texas limited liability company,
US LITHOTRIPSY, L.P., a Texas limited partnership, USMD CANCER TREATMENT CENTERS, L.L.C., a Texas limited liability company, USMD CANCER TREATMENT CENTERS GP, L.L.C., Texas limited liability company, USMD PPM, LLC, a Texas limited liability company,
USMD DIAGNOSTIC SERVICES, LLC, a Texas limited liability company, MAT-RX FORT WORTH GP, L.L.C., a Texas limited liability company, USMD ADMINISTRATIVE SERVICES, L.L.C., Texas limited liability company, USGP, LLC., a Texas limited liability company,
LITHO GP, LLC., a Texas limited liability company, METRO I STONE MANAGEMENT, LTD., a Texas limited partnership, USMD AFFILIATED SERVICES, a Texas not for profit corporation, MEDICAL CLINIC OF NORTH TEXAS PLLC, a Texas professional association, and
USMD CTC (MO), LLC, a Missouri limited liability company (individually a “Borrower” and collectively, the “Borrowers”), the undersigned Lenders (as defined below), and JPMORGAN CHASE BANK, N.A., as administrative
agent for the Lenders (the “Administrative Agent”). 
 PRELIMINARY STATEMENTS: 

(1) The Borrowers, the lenders party thereto (the “Lenders”), and the Administrative Agent have entered into a Credit
Agreement dated as of August 31, 2012, as amended by that certain Amendment No. 1 to Credit Agreement dated as of February 28, 2013, as amended by that certain Amendment No. 2 to Credit Agreement dated as of September 13,
2013 (the “Credit Agreement”). 
 (2) The Borrowers have requested, and, upon Section 2 of this Amendment becoming
effective, the Lenders and the Administrative Agent have agreed, that certain provisions of the Credit Agreement be amended in the manner provided for in this Amendment. 

NOW, THEREFORE, in consideration of the premises contained herein and for other good and valuable consideration, the receipt and sufficiency
of which are hereby acknowledged, the parties hereto, intending to be legally bound hereby, agree as follows: 
 SECTION 1. Defined
Terms. Terms defined in the Credit Agreement and used herein shall have the meanings given to them in the Credit Agreement. 

SECTION 2. Amendments to Credit Agreement. The Credit Agreement is, effective as of the Amendment No. 3 Effective Date,
hereby amended as follows: 
 (a) The following defined terms are hereby added to Section 1.01 of the Credit Agreement in their correct
alphabetical locations: 

 “Consolidated Senior Indebtedness” means, at any date, the
Consolidated Total Indebtedness of the Borrowers minus the outstanding principal of the Subordinated Debt and the Convertible Notes on such date. 

“Consolidated Total Indebtedness” means, at any date, the aggregate principal amount of all Indebtedness of
the Borrowers at such date, determined on a consolidated basis in accordance with GAAP. 
 “Designated
Person” means a Person: 
 (a) listed in the annex to, or otherwise the subject of the provisions of, any Executive
Order; 
 (b) named as a “Specially Designated National and Blocked Person” (“SDN”) on the most
current list published by OFAC at its official website or any replacement website or other replacement official publication of such list; or is otherwise the subject of any Sanctions Laws and Regulations; or 

(c) in which a Person on the SDN List has 50% or greater ownership interest or that is otherwise controlled by an SDN. 

“Sanctions Laws and Regulations” means any sanctions, prohibitions or requirements imposed by any executive
order (an “Executive Order”) or by any sanctions program administered by the U.S. Department of the Treasury Office of Foreign Assets Control (“OFAC”). 

“Senior Leverage Ratio” means, as at the last day of any period, the ratio of (a) Consolidated Senior
Indebtedness on such day to (b) Consolidated EBITDA for such period. 
 (b) The definition of “Anti-Terrorism Order” is hereby
deleted from Section 1.01 of the Credit Agreement. 
 (c) In the definition of “Revolving Termination Date” contained in
Section 1.01 of the Credit Agreement, the date “February 28, 2014” is hereby amended to read “June 30, 2015”. 
 (d)
Section 4.24 of the Credit Agreement is hereby amended and restated in its entirety as follows: 
 “Section 4.24.
Sanctions Laws and Regulations. None of the Borrowers, or to the best of their knowledge any of their respective directors, officers, brokers or other agents acting or benefiting in any capacity in connection with any of the Facilities, or
any of its respective parents, Subsidiaries, or Affiliates, is a Designated Person.” 

  
 -2- 

 (e) The following Section 5.13 is hereby added to the Credit Agreement in its correct
numerical location: 
 “Section 5.13. Sanction Laws and Regulations. 

(a) The Borrowers shall not, directly or indirectly, use the proceeds of any of the Facilities, or lend, contribute or
otherwise make available such proceeds to any Subsidiary, joint venture partner or other Person (a) to fund any activities or business of or with any Designated Person, or in any country or territory, that at the time of such funding is the
subject of any sanctions under any Sanctions Laws and Regulations, or (ii) in any other manner that would result in a violation of any Sanctions Laws and Regulations by any party to this Agreement. 

(b) None of the funds or assets of the Borrowers that are used to pay any amount due pursuant to the this Agreement or any
other Loan Document shall constitute funds obtained from transactions with or relating to Designated Persons or countries which are the subject of sanctions under any Sanctions Laws and Regulations.” 

(f) Paragraph (a) of Section 6.01 of the Credit Agreement is hereby amended and restated in its entirety to read as follows: 

“(a) Fixed Charge Coverage Ratio. Permit the Fixed Charge Coverage Ratio as at the last day of any period of four
consecutive Fiscal Quarters of the Borrowers ending during any test period set forth below to be less than the ratio set forth below opposite such test period: 
  

					
	 Test Period
	  	 Fixed Charge Coverage Ratio
	 
	 From and including December 31, 2012 through and including December 31, 2013
	  	 	1.50 to 1.00	  
	 From and including March 31, 2014 and Thereafter”
	  	 	1.25 to 1.00	  

 (g) The following paragraph (d) is hereby added to Section 6.01 of the Credit Agreement after
paragraph (c) thereof: 
 “(d) Senior Leverage Ratio. Permit the Senior Leverage Ratio as at the last day of
any period of four consecutive Fiscal Quarters of the Borrowers ending during any test period set forth below to exceed the ratio set forth below opposite such test period: 
  

					
	 Test Period
	  	 Senior Leverage Ratio
	 
	 From and including December 31, 2013 through and including September 30, 2014
	  	 	1.50 to 1.00	  
	 From and including December 31, 2014 and Thereafter”
	  	 	1.25 to 1.00	  

  
 -3- 

 (h) Exhibit B of the Credit Agreement is hereby amended and restated in its entirety in
the form of Annex A hereto. 
 SECTION 3. Conditions of Effectiveness. This Amendment shall become effective when, and
only when, on or before February 25, 2014, the Administrative Agent shall have received counterparts of this Amendment duly executed and delivered by all of the Borrowers and all of the Lenders, and Section 2 of this Amendment shall become
effective as of the Amendment No. 3 Effective Date when, and only when, on or before February 25, 2014, all of the following conditions precedent have been satisfied: 

(a) Fees and Expenses. The Administrative Agent shall have received evidence that the Borrowers shall have paid to the Administrative
Agent all reasonable out-of-pocket fees and expenses of the Administrative Agent incurred in connection with this Amendment and the transactions contemplated hereby (including, to the extent invoiced, the reasonable out-of-pocket fees, disbursements
and charges of counsel to the Administrative Agent). 
 (b) Amendment Fee. The Borrowers shall have paid to the Administrative Agent,
for the account of the Lenders, an amendment fee in the aggregate amount of $50,000.00. 
 SECTION 4. Representations and Warranties
of the Borrowers. To induce the Administrative Agent and the Lenders to enter into this Amendment, each of the Borrowers hereby represents and warrants to the Administrative Agent and all of the Lenders as of the date hereof that: 

(a) Existence, etc. Each Borrower is duly organized, validly existing and in good standing under the laws of the jurisdiction indicated
in the preamble of this Amendment. 
 (b) No Legal Bar. Each Borrower has the power, authority, and legal right to execute, deliver
and perform its obligations under this Amendment and each other document or instrument required to be executed and delivered by it hereunder. The execution, delivery and performance by each Borrower of this Amendment and each other document or
instrument required to be executed and delivered by any Borrower hereunder have been duly authorized by all necessary organizational action and do not (i) contravene or violate any of the Organizational Documents of any Borrower,
(ii) violate any Requirement of Law, (iii) violate any Contractual Obligation binding on or affecting any Borrower or any of its assets, or (iv) result in, or require, the creation or imposition of any mortgage, deed of trust, pledge,
Lien, security interest or other charge, encumbrance or preferential arrangement of any nature (other than pursuant to the Security Documents) upon or with respect to any of the properties now owned or hereafter acquired by any of the Borrowers.

 (c) Approvals. No consent or authorization of, approval by, notice to, filing with or other act by or in respect of, any
Governmental Authority or any other Person is required in connection with the execution, delivery and performance of this Amendment by any of the Borrowers. 

(d) Enforceable Obligations. This Amendment has been duly executed and delivered by each Borrower. This Amendment and each of the other
Loan Documents to which any Borrower is a party constitutes a legal, valid and binding obligation of each Borrower that is a party thereto enforceable against each such Borrower in accordance with its respective terms, except as enforceability may
be limited by bankruptcy, insolvency, reorganization, moratorium and other similar laws affecting the enforcement of creditors’ rights generally and general equitable principles. 

  
 -4- 

 (e) Security Documents. The Security Documents constitute valid and perfected security
interests and liens in and to the Collateral covered thereby with the priority required thereunder and secure the payment and performance of the Secured Obligations, and all action required to perfect fully such security interests and liens has been
taken and completed, and the execution, delivery and performance of this Amendment do not adversely affect such security interests and liens. 

(f) No Default. No Default or Event of Default exists before or immediately after giving effect to this Amendment. 

(g) Representations and Warranties. The representations and warranties made by each of the Borrowers in the Credit Agreement and the
other Loan Documents are true and correct in all material respects on and as of the date hereof, before and after giving effect to the effectiveness of this Amendment (except to the extent such representations and warranties relate, by their terms,
to a specific earlier date, in which case they shall be true and correct on and as of such earlier date). 
 SECTION 5. Reference to
and Effect on the Loan Documents. (a) Upon the effectiveness of this Amendment, on and after the date hereof each reference in the Credit Agreement to “this Agreement”, “hereunder”, “hereof” or words of like
import referring to the Credit Agreement, and each reference in the other Loan Documents to “the Credit Agreement”, “thereunder”, “thereof” or words of like import referring to the Credit Agreement, shall mean and be a
reference to the Credit Agreement as amended hereby. 
 (b) Except as specifically amended or modified above, the Credit Agreement and all
other Loan Documents, are and shall continue to be in full force and effect in accordance with their respective terms and are hereby in all respects ratified and confirmed by each Borrower. 

(c) The execution, delivery and effectiveness of this Amendment shall not, except as expressly provided herein, operate as a waiver of any
right, power or remedy of any Lender or the Administrative Agent under any of the Loan Documents, nor constitute a waiver of any provision of any of the Loan Documents. 

(d) This Amendment is a Loan Document in all respects and for all purposes, and all provisions of the Credit Agreement pertaining to the Loan
Documents apply hereto and thereto. 
 SECTION 6. Costs and Expenses. The Borrowers jointly and severally agree to pay or
reimburse the Administrative Agent on demand for all of its out-of-pocket costs and reasonable expenses incurred in connection with this Amendment, any other documents prepared in connection herewith and the transactions contemplated hereby,
including, without limitation, the reasonable fees and disbursements of counsel to the Administrative Agent. 

  
 -5- 

 SECTION 7. Binding Agreement. This Amendment shall be binding on the parties hereto
and their respective successors and assigns; provided, however, that none of the Borrowers may assign or delegate any of its rights or obligations hereunder without the prior written consent of the Administrative Agent and each Lender.

 SECTION 8. Execution in Counterparts. This Amendment may be executed in any number of counterparts and by different parties
hereto in separate counterparts, each of which when so executed and delivered shall be deemed to be an original and all of which taken together shall constitute but one and the same agreement. Delivery of an executed counterpart of a signature page
of this Amendment by facsimile or in electronic (i.e., “pdf” or “tif”) format shall be effective as delivery of a manually executed counterpart of this Agreement. 

SECTION 9. Governing Law. This Amendment shall be governed by, and construed in accordance with, the laws of the State of Texas.

 SECTION 10. Headings. The section headings hereof are inserted for convenience of reference only and shall in no way alter,
amend, define or be used in the construction or interpretation of the text of such section. 
 SECTION 11. ENTIRE AGREEMENT.
THIS AMENDMENT, THE CREDIT AGREEMENT AND THE OTHER LOAN DOCUMENTS COLLECTIVELY REPRESENT THE FINAL AGREEMENT AMONG THE PARTIES AND MAY NOT BE CONTRADICTED BY EVIDENCE OF PRIOR, CONTEMPORANEOUS, OR SUBSEQUENT ORAL AGREEMENTS OF THE PARTIES. THERE ARE
NOT UNWRITTEN ORAL AGREEMENTS AMONG THE PARTIES. 
 [Signature Pages Follow] 

  
 -6- 

 IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be executed and delivered by
their proper and duly authorized officers as of the date first above written. 
  

			
	ADMINISTRATIVE AGENT:
	
	 JPMORGAN CHASE BANK, N.A.,

as Administrative Agent

		
	By: 	 	/s/ J. Michael Wilson
	Name:	 	J. Michael Wilson
	Title:	 	Senior Vice President

 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	LENDERS:
	
	JPMORGAN CHASE BANK, N.A.,
		
	By:	 	/s/ J. Michael Wilson
	Name:	 	J. Michael Wilson
	Title:	 	Senior Vice President

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	CAPITAL ONE, NATIONAL ASSOCIATION
		
	By:	 	 /s/ Michael Barber

	Name:	 	Michael Barber
	Title:	 	Senior Vice President

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	TEXAS CAPITAL BANK, NATIONAL ASSOCIATION
		
	By:	 	 /s/ Leslie J. Tiezen

	Name:	 	Leslie J. Tiezen
	Title:	 	Senior Vice President

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	SOUTHWEST BANK,
	a Texas State Bank
		
	By:	 	 /s/ Josh Burleson

	Name:	 	Josh Burleson
	Title:	 	Vice President

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	BORROWERS:
	
	USMD HOLDINGS, INC.
		
	By:	 	/s/ Gordon Davis
		 	  

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	IMPEL MANAGEMENT SERVICES, L.L.C.
		
	By:	 	USMD Holdings, Inc., its sole member
		
	By:	 	/s/ Gordon Davis
		 	  

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	IMPEL CONSULTING EXPERTS, L.L.C.
		
	By:	 	Impel Management Services, L.L.C., its sole member
		
	By:	 	USMD Holdings, Inc., its sole member
		
	By:	 	/s/ Gordon Davis
		 	  

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	USMD INC.
		
	By:	 	/s/ Gordon Davis
		 	  

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	MAT-RX DEVELOPMENT, L.L.C.
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
		 	  

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	MAT-RX FORT WORTH GP, L.L.C.
		
	By:	 	MAT-RX DEVELOPMENT, L.L.C., its sole member
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
		 	  

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	USMD OF ARLINGTON GP, L.L.C.
		
	By:	 	MAT-RX DEVELOPMENT, L.L.C., its sole member
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	USGP, LLC.
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	US LITHOTRIPSY, L.P.
		
	By:	 	USGP, LLC., its general partner
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	LITHO GP, LLC.
		
	By:	 	US Lithotripsy, L.P., its sole member
		
	By:	 	USGP, LLC., its general partner
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	METRO I STONE MANAGEMENT, LTD.
		
	By:	 	Litho GP, LLC., its general partner
		
	By:	 	US Lithotripsy, L.P., its sole member
		
	By:	 	USGP, LLC., its general partner
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	USMD ADMINISTRATIVE SERVICES, L.L.C.
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	USMD DIAGNOSTIC SERVICES, LLC
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	USMD PPM, LLC
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	USMD CANCER TREATMENT CENTERS, L.L.C.
		
	By:	 	USMD Inc., its sole member
		
	By:	 	/s/ Gordon Davis
	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	USMD CANCER TREATMENT CENTERS GP, L.L.C.
		
	By:	 	USMD Cancer Treatment Centers, L.L.C., its sole member
		
	By:	 	USMD Inc., its sole member
		
	By:	 	 /s/ Gordon Davis

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	USMD AFFILIATED SERVICES
		
	By:	 	 /s/ Gordon Davis

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	MEDICAL CLINIC OF NORTH TEXAS PLLC
		
	By:	 	USMD Affiliated Services, its sole member
		
	By:	 	 /s/ Gordon Davis

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 
			
	UROLOGY ASSOCIATES OF NORTH TEXAS, P.L.L.C.
		
	By:	 	USMD Affiliated Services, its sole member
		
	By:	 	 /s/ Gordon Davis

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer
	
	 USMD CTC (MO), LLC,
 a
Missouri limited liability company

		
	By:	 	USMD Cancer Treatment Centers, L.L.C., its sole member
		
	By:	 	USMD Inc., its sole member
		
	By:	 	 /s/ Gordon Davis

	Name:	 	Gordon Davis
	Title:	 	Chief Accounting Officer

  
 Signature Page 

Amendment No. 3 to Credit Agreement 

 ANNEX A 

FORM COMPLIANCE CERTIFICATE

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