Consent to Telehealth Services

I. Introduction

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. This may include synchronous communication (real-time video and audio) and asynchronous communication (secure messaging, questionnaires, and photo sharing).

By using the ForgeMeds platform, you are agreeing to receive clinical services via telehealth from independent, state-licensed healthcare providers affiliated with our network (the "Medical Groups").

II. Expected Benefits

The use of telehealth may provide the following benefits:

• Easier and more efficient access to medical care and treatment.
• Reduced wait times and the elimination of travel time to a physical clinic.
• More convenient and ongoing communication with your care team.

III. Possible Risks

While telehealth is a safe and effective way to receive care for many conditions, there are inherent risks, which include, but are not limited to:

• Information insufficiency: The information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision-making by the provider.
• Lack of physical examination: The inability to conduct a hands-on physical examination may lead to missed diagnoses or incorrect treatment plans.
• Technology failures: Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• Security risks: Although we use HIPAA-compliant systems and robust security protocols, in rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

IV. Patient Rights & Responsibilities

You have certain rights and responsibilities when receiving telehealth services:

• Right to Withdraw Consent: You have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment.
• Right to Records: You have the right to inspect all medical information transmitted during a telehealth consultation, and you may receive copies of this information.
• Alternative Care: You understand that a variety of alternative methods of medical care may be available to you (e.g., in-person visits to a local doctor), and that you may choose one or more of these at any time.
• Responsibility to Provide Accurate Information: You agree to provide your healthcare provider with accurate, complete, and current information about your health history, current medications, and any symptoms you are experiencing.

V. Data Sharing & Affiliated Entities

By proceeding, you understand and agree that your personal health information will be shared with the independent Medical Groups reviewing your case, as well as with independent, licensed 503A or 503B compounding affiliate pharmacies for the purpose of fulfilling any prescribed medications. ForgeMeds acts solely as a technology platform to facilitate this connection.

VI. Acknowledgment and Consent

By clicking "I Agree," "Submit," or checking the required consent box during the onboarding or assessment process, you acknowledge that:

• You have read and understand the information provided above regarding telehealth.
• You have had the opportunity to ask questions about this information and all your questions have been answered to your satisfaction.
• You understand the risks and benefits of telehealth, and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.