Consent to Telehealth Page

Hey!

We think access is critically important at TBD Health – which is why we leverage telemedicine. Please read the below prior to requesting any of the services available at TBD Health Inc.’s website, www.tbd.health (the “Website”) or our online portal (the “Application,” and collectively with the Website, the “Telehealth Services”).

CONSENT TO TELEHEALTH SERVICES

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 treatment and/or subsequent treatment(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

Telehealth 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, I, the patient, understand and agree to the following:

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

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

3. I have the right to withhold or withdraw my consent to the use of Telehealth Services in the ongoing course of my care at any time.

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

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

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

7. It is my duty to inform my TBD Health, Inc. provider of all information provided by or obtained from my other health care professionals that may be relevant to the care and services I receive from TBD Health Inc.

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

By continuing, I, the patient, hereby:

Represent that I have read this Consent to Telehealth Services completely and carefully, and that I understand the anticipated benefits and risks relating to the Telehealth Services furnished to me pursuant to the TBD Health Inc. Website or Application.

Give my consent to the use of Telehealth Services rendered by providers engaged through the TBD Health Inc. Application.

You understand that by clicking on the checkbox when creating your TBD Health Inc. account, you are agreeing to the terms set forth herein, effective as of that day, and that such action constitutes a legal signature.