Informed Consent Regarding Use of Telehealth

Purpose

The purpose of this consent form ("Consent") is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians ("Providers") using the online platform owned and operated by Levelheaded Health, LLC and/or its affiliates (the "Service"). In this Consent, the terms "you" and "yours" refer to the person using the Service. The Service is intended solely for use by adults age eighteen (18) and older; Levelheaded Health, LLC does not knowingly provide services to, or collect information from, individuals under the age of eighteen (18).

Use of Telehealth

Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to, one or more of the following: electronic transmission of medical records, photo images, personal health information or other data between a patient and a Provider; interactions between a patient and Provider via audio, video and/or data communications (such as messaging or email communications); use of output data from medical devices, sound and video files. Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with your Provider.

Anticipated Benefits

The use of telehealth may have the following possible benefits: making it easier and more efficient for you to access medical care for the conditions treated by your Provider(s); allowing you to obtain medical care by Provider(s) at times that are convenient for you; and enabling you to interact with Provider(s) without the necessity of an in-office appointment.

Potential Risks

While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to the following: the quality, accuracy or effectiveness of the services you receive from your Provider could be limited; technology, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Service, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost; failures of technology may also impact your Provider(s) ability to correctly diagnose or treat your condition; the inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you; your Provider(s) may not be able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services; delays in medical evaluation/treatment could occur due to unavailability of your Provider(s) or deficiencies or failures of the technology or electronic equipment used; the electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your medical or other information; data stored and communicated electronically, for example, through email communications, may be more susceptible to unintended disclosure of protected health information to third parties; given regulatory requirements in certain jurisdictions, your Provider(s) diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited; a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

GLP-1 Medication-Specific Risks and Disclosures

Certain Providers using the Service may prescribe compounded glucagon-like peptide-1 (GLP-1) receptor agonist medications as part of a longevity- and wellness-oriented protocol. You acknowledge and agree to the following:

• Compounded status. The GLP-1 medications available through the Service are compounded formulations prepared by a licensed pharmacy pursuant to a Provider's prescription. Compounded medications are not independently reviewed, approved, or verified for safety, efficacy, or quality by the U.S. Food and Drug Administration (FDA) in the same manner as an FDA-approved, manufacturer-produced drug product. Potency, purity, and formulation may vary by compounding pharmacy and by batch.
• Use outside an FDA-approved indication. GLP-1 medications carry FDA-approved indications for certain metabolic conditions. Use of a GLP-1 medication for longevity, general wellness, or any purpose outside its FDA-approved indication ("off-label use") has not been independently evaluated by the FDA for that purpose. Your Provider will discuss the rationale for any off-label use, the supporting evidence available, and the alternatives to such use, prior to prescribing.
• Known and potential side effects. Reported side effects associated with GLP-1 medications include, but are not limited to, nausea, vomiting, diarrhea, constipation, abdominal pain, decreased appetite, fatigue, injection-site reactions, gallbladder-related events, pancreatitis, and, rarely, more serious gastrointestinal or thyroid-related events. You should discuss your full medical history, including any personal or family history of thyroid cancer, pancreatitis, or gastrointestinal disease, with your Provider before beginning treatment.
• Contraindications and interactions. Certain individuals should not use GLP-1 medications, including individuals with a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2, and individuals who are pregnant, planning to become pregnant, or breastfeeding. GLP-1 medications may interact with other medications you are taking, including other medications used to manage blood sugar. You must disclose your complete medication and supplement history to your Provider.
• No guarantee of results. Individual results from GLP-1 therapy vary, and no specific outcome, weight change, or wellness result is guaranteed.

Life-Threatening and Other Emergency Situations; Follow-Up Care

If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Service. If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number:

Data Privacy and Protection

The electronic systems used in the Service will incorporate network and software security protocols to protect the privacy and security of your information and will include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, certain administrative purposes, and as required by law to disclose to other persons and agencies certain information obtained during the provision of services (e.g., danger to self or others; mandatory reporting of child, elder, or vulnerable adult abuse) or as otherwise set forth in your Provider's Notice of Privacy Practices. Use of the Service may include email communications to and from you that may include your protected health information. You understand that Levelheaded Health, LLC does not and cannot guarantee the security or privacy of the services you use to receive communications, including for example your email service provider.

Open Payments Notice

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payments and other transfers of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at openpaymentsdata.cms.gov.

Your Acknowledgments

By clicking "I Agree," checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following:

1. Healthcare services provided to you by Providers via the Service will be provided by telehealth. Your treating Provider will be a physician.
2. Certain technology, including the Service, may be used while still in a beta testing and development phase, and before such technology is a final and finished product. Technology used to deliver care, including the Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from your Provider(s).
3. The delivery of healthcare services via telehealth is an evolving field and the use of telehealth or other technology in your medical care and treatment from Provider(s) may include uses of technology different from those described in this Consent or not specifically described in this Consent. No potential benefits from the use of telehealth or other technology or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment by your Provider(s). Your condition may not be cured or improved, and in some cases, may get worse.
4. There are limitations in the provision of medical care via telehealth and technology, including the Service, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment. There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent.
5. You have the opportunity to discuss the use of telehealth, including the Service, with your Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth.
6. You understand that there will be no recording of any online treatment sessions by your Provider(s) or you.
7. Your Provider(s) will assess your medical condition and, in their sole discretion, may determine it is medically appropriate to diagnose and/or treat your condition via telehealth and whether you maintain sufficient knowledge and skills in the use of technology appropriate to diagnosing and/or treating your condition via telehealth.
8. By continuing to use the Service, you concur with your Provider's medical assessment and agree to receive a diagnosis and/or treatment via telehealth technology. You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which you are entitled, but you understand that the Providers who utilize the Service do not offer in-person treatment. Any withdrawal of your consent will be effective upon receipt of written notice to your Providers, except that such withdrawal will not have any effect on any action taken by Levelheaded Health, LLC or your Provider(s) in reliance on this Consent before it received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent.
9. You understand that the use of the Service involves electronic communication to and from you of your personal medical information in connection with the provision of telehealth services, including through email.
10. You understand that it is your duty to provide Levelheaded Health, LLC and your Provider(s) truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from other healthcare providers, including emergency contact information for your local healthcare providers. You understand that each of your Provider(s) may determine in their sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Service, and that you may need to seek care and treatment from a specialist or other healthcare provider, outside of such telehealth technology.
11. Levelheaded Health, LLC has a commercial and financial relationship with the medical group whose physicians provide services through the Service, MDI Medical Group PC, including the entity that employs or contracts with your Provider. You are free to obtain your medical examination from another healthcare provider that is not associated with Levelheaded Health, LLC.
12. Levelheaded Health, LLC will use its pharmacy partner(s) to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. Prescriptions may be filled by and transferred between any pharmacy partners on your behalf. You must pay the full amount of the costs associated with use of the Service, including any prescription you may receive. Levelheaded Health, LLC does not accept insurance; the Service is offered on a self-pay basis only, and you agree not to attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer for services received through the Service.
13. If you have a concern about a Provider, you may contact the medical board that licenses that Provider in the state in which the Provider is licensed. Contact information for state medical boards is available through the Federation of State Medical Boards at fsmb.org.