Consent to Treatment & Telehealth Page

Hey!

We think healthcare access is critically important at TBD Health, Inc. (“TBD Health”) – which is why we facilitate your access to health care services through TBD Health’s website, www.tbd.health (the “Website”) or our online portal (the “Application,”) with our third-party licensed health care provider partners and clinical medical laboratories (collectively, the “Providers”). By clicking “I accept” you (a) certify that you are the patient receiving health care services and that you have read, understood and agree to all of the terms and conditions set forth in this Consent to Treatment and Telehealth (the “Consent”), and (b) give your informed consent to receive health care services under the terms described in this Consent. Please carefully review the information in this Consent document before accepting.

CONSENT TO TELEHEALTH SERVICES

You acknowledge, understand, and voluntarily consent to medical treatment and healthcare related services described herein (“Healthcare Services”) from the Providers, including, without limitation, the collection of blood, saliva, nasal, vaginal or urine sample for submission to a third party laboratory for performance of a sexually transmitted infection test which may include HIV testing (each a “Test”). You acknowledge that this Consent is voluntary and is not required. You may wish to speak with one of the Providers or your primary care provider prior to proceeding with any Healthcare Services. The Healthcare Services will not be available to you unless you accept and acknowledge in writing that you have read, understood, and agree to this Consent.

The Healthcare Services are provided by the Providers. The Providers may be physicians, nurse practitioners, physician’s assistants, or nurses. You consent to receive Healthcare Services, including Telehealth Services (as defined below), from the Providers. TBD Health does not provide health care services or the Telehealth Services. It performs administrative, payment, and other non-clinical services for you and the Providers.

This Consent provides the Providers with your permission to: (1) perform care and treatment; (2) conduct reasonable and necessary examinations, laboratory tests, and procedures; (3) administer medication and treatment as may be directed by the treating provider; and (4) disclose certain information regarding the Healthcare Services to TBD Health. By signing below, you are indicating that you intend that this Consent is continuing in nature even after a specific diagnosis has been made and treatment recommended. The Consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your Provider about the purpose, potential risks and benefits of any test or treatment ordered for you. If you have any concerns regarding any test or treatment recommend by your Provider, we encourage you to ask questions.

By agreeing to and accepting the terms and conditions of this Consent, you voluntarily request a Provider to perform reasonable and necessary examination, testing and treatment for the condition which has brought you to seek care. You understand that if additional testing, invasive or interventional procedures are recommended, you will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

CONSENT TO TELEHEALTH SERVICES

All Healthcare Services are made available to you virtually via telehealth services accessible through the Website and the Application (such services, together with the Website and the Application, the “Telehealth Services”). The Telehealth Services will be provided by the Providers who are located at sites remote from you. Telehealth involves the use of telehealth questionnaires, audio, video, or other electronic communications by your health care provider for the purpose of interacting with you, consulting with you and/or other health professionals responsible for your care, and/or reviewing your medical information for the purpose of providing medical treatment, therapy, follow-up, education, and/or obtaining medical information for the purposes of determining whether to order laboratory tests to inform diagnoses. During your telehealth consultation, details of your medical history and personal health information may be discussed with you or other health professionals through the use of interactive audio, video, or other telecommunications technology. Additionally, a physical examination of you, as well as other treatment steps, may take place, and audio, video, and/or photo recordings may be taken and used during the course of such examination and/or subsequent examination(s).

Electronic systems used during your telehealth encounter will incorporate network and software security protocols to protect the privacy and security of your health information and imaging data, and will include measures to safeguard your data to ensure its integrity against intentional or unintentional corruption.

Anticipated Benefits of Telehealth Telehealth may provide the following patient benefits: Improved access to health care services, by enabling you, the patient, to remain in your location while the health care provider may provide services to you from a distant site; More efficient medical evaluation and management; The opportunity to obtain expertise from a distantly located provider; Enabling ongoing care and follow-up communication with a health care provider. ** Possible Risks of Telehealth** As with any type or form of health care treatment, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to: Delays in medical evaluation / treatment could occur due to deficiencies or failures of the electronic equipment; In rare instances, security protocols could fail, causing a breach of privacy of your personal medical information; In rare cases, a lack of access to all of your medical records may result in errors in medical judgment.

NOT FOR EMERGENCIES

The Application is designed for routine, non-emergency consultations. You should never use the Application in an emergency. By signing this consent, you acknowledge your understanding that, in an emergency, you should dial 911 or go to an emergency department.

NOT IN PLACE OF A PRIMARY CARE PHYSICIAN RELATIONSHIP

Healthcare Services, including the Telehealth Services furnished pursuant to the Application, are intended to be an addition to, and not a replacement for, your primary care practitioner’s services. Responsibility for your overall care should remain with your primary care practitioner, if you have one, and we strongly encourage you to locate one if you do not.

By consenting to this form, you, understand and agree to the following statements:

1. While you may expect the anticipated benefits from the use of Telehealth Services in your care, no results can be guaranteed.

2. The federal and applicable state laws that protect the privacy and security of your health information apply to the Telehealth Services, and no information obtained in the use of Telehealth Services which identifies you will be disclosed to researchers or other entities without your authorization.

3. You have the right to withhold or withdraw your consent to the use of Telehealth Services in the ongoing course of your care at any time, however you recognize that this may impact your ability to receive services from other Providers or the utility of any tests, products, or services you receive from TBD Health.

4. You have the right to inspect all information obtained and recorded in the course of the Telehealth Services, and you may receive copies of this information for a reasonable fee.

5. A variety of alternative methods of medical care may be available to you, and you may choose one or more of these at any time. You understand that the licensed health care provider you engage with through the Telehealth Services will explain these alternatives to your satisfaction.

6. Telehealth Services may involve electronic communication of your personal medical information to other health care providers who may be located in other areas, including outside of the state in which you reside.

7. It is your duty to inform your Provider of all information provided by or obtained from your other health care professionals that may be relevant to the care and services you receive through the Telehealth Services.

8. You consent to receive protected health information via email or SMS text messaging and you understand that messages shared through these communication channels may not be secure in every instance.

By continuing, you, hereby:

1. Represent that you have read this Consent completely and carefully, and that you understand the anticipated benefits and risks relating to the Telehealth Services furnished to you utilizing to the Website or Application.

2. Give your consent to the use of Telehealth Services rendered by Providers engaged through the Application.

3. Understand that by clicking on the checkbox when creating your TBD Health account, you are agreeing to the terms set forth herein, effective as of that day, and that such action constitutes a legal signature. ** Records Transfer to Primary Care Providers** If you need assistance sending records of the Telehealth Services you receive to your primary care provider, please contact hello@tbd.health.

Formal Complaints If you would like to file a formal complaint regarding any Provider from whom you receive Telehealth Services, you should contact your state’s medical board.

CONSENT FOR SPECIMEN COLLECTION AND TESTING

TBD Health provides you with the opportunity to purchase certain laboratory tests, the specimen for which is performed by you, at home, via self-collection (the “At-Home Tests”). The diagnostic evaluation and testing of the specimen for the At-Home Tests will be conducted at certain CLIA certified laboratories. You understand, acknowledge, and agree that TBD Health is not a laboratory and does not manufacture or own any laboratory tests or medical devices.
** About the At-Home Tests ** Each of the specimen collections necessary for the At-Home Tests available on the Website will be performed via self-collection. Information about the At-Home Tests can be found on the Website. For the most up to date information about your testing options, please contact us at hello@tbd.health. Use of Your Specimen and Information

Your blood, saliva, nasal, vaginal or urine specimen, along with your other personal information will be sent for analysis to a CLIA-certified laboratory facility licensed by the State of Nevada. Upon successful completion of the At-Home Test, the results will be sent to TBD Health, and TBD Health will make the results available on your online portal account/your online portal account for your review. Once testing is completed, your specimen will not be used for any purpose other than that described within this Consent.

Benefits of the Test The purpose of the At-Home Test on your collected specimen is to determine whether you may have a sexually transmitted infection. Risks of Specimen Collection
Depending on the manner of specimen collection for the applicable At-Home Test, there may be a risk of injury (e.g., accidental finger prick) in collecting your specimen, as with any medical procedure. This risk is minimal based on nature/manner of collection. ** Risks and Limitations of the At-Home Test ** The At-Home Test is a diagnostic test for various sexually transmitted infections including HIV, as described on the Website. The At-Home Test may cause you to discover sensitive information about your health. With all medical tests, there is a chance of a false positive or a false negative result. A false positive result means the At-Home Test result incorrectly reports that you have a sexually transmitted infection. A false negative result means the At-Home Test result incorrectly reports that you do not have a sexually transmitted infection. There are also window periods related to sexually transmitted infections where the infection may not show up on laboratory tests for a certain period of time. Other sources of error, while rare, include specimen mix-up, poor specimen quality or contamination, and technical errors in the laboratory. In addition, if you have certain rare biological conditions or have had certain bone marrow, kidney, liver or heart transplants, transfusions, or hematologic malignancies, these conditions may limit the accuracy or relevance of the results or prevent the At-Home Test from being completed. TBD Health expressly disclaims any liability for the inaccuracy of At-Home Test results due to such conditions or the failure to provide accurate, correct or complete information, and you expressly waive any claims against TBD Health with respect thereto.

**Potential Results of Testing ** The result of the At-Home Test is the determination of whether you have an applicable sexually transmitted infection.

Consent to At-Home Testing* By accepting and agreeing to the terms and conditions of this Consent, you freely and voluntarily consent to receive the At-Home Test, and specifically agree, acknowledge and consent to the following statements:

● The specimen being provided is yours and you are at least 14 years of age. ● You are consenting to the collection of the applicable type of specimen collection. ● The At-Home Test is intended for diagnostic purposes. ● The reported results and information are intended solely for a diagnostic use. You should not make any medical decisions or medication changes based on these results without speaking to a health care provider first. Your health care provider remains ultimately responsible for all diagnosis and treatment decisions. ● The reported results may be subject to state law health reporting requirements. ● TBD Health facilitates access to Providers for consults after receipt of your At-Home Test results through your online portal account. These Providers will be available through the Telehealth Services described in this Consent.
● You understand that your specimen will not be used by any person for purposes beyond submission to the appropriate third party laboratory for the Test.

INFORMATION COLLECTED AND USE AND DISCLOSURE

In connection with your receipt of Healthcare Services and administration of any At-Home Test, you will be asked to provide certain health and other personal information, such as name, address, date of birth, and certain medical history. In order for the Healthcare Services and the At-Home Test to be performed as intended, the information provided must be accurate and complete. If another person is submitting this information on your behalf, by signing this Consent, you represent and warrant that such person is authorized to provide such information, and that all such information is accurate and correct.

If you are seeking a Test you will also be asked to provide a blood, saliva, nasal, vaginal or urine specimen in accordance with specified collection procedures by an authorized medical professional as described above.

You acknowledge and agree that you have provided certain personal information to TBD Health in connection with your use of the Website and that TBD Health may provide any such information to any Provider for purposes of fulfilling your request to obtain the Healthcare Services or At-Home Test, in accordance with the terms and conditions in our Privacy Policy, available here: https://www.tbd.health/privacy-policy

You further acknowledge and agree that, in order to facilitate your access to the Healthcare Services and the purposes of the At-Home Tests, the Providers (including any licensed health care providers and laboratories) are expressly authorized to disclose information they obtain from you or about you to TBD Health, including, but not limited to, information about any Telehealth Services you receive, diagnoses, treatment plans, test results, and follow-up care. You acknowledge and agree that TBD Health may use and disclose any information received from the Providers in accordance with our Privacy Policy, available here: https://www.tbd.health/privacy-policy