Consent to Telehealth

Thank you for choosing RespondWell, LLC (“RespondWell”). RespondWell operates the Platform and provides related administrative support services that facilitate access to care. Clinical Services are not provided by RespondWell. Clinical Services are provided by Providers affiliated with one or more licensed medical groups or professional entities (each, a “Practice” or “Medical Group”), including Wasef Health, P.C. (“Wasef”) and any other Practice that may be added to the Platform from time to time. Your Provider may be a licensed physician, physician assistant, nurse practitioner, or other licensed clinician authorized to provide care in your state, where required.

You are viewing this Consent because you have elected to engage in telehealth Clinical Services through the Platform with a Provider affiliated with a Practice.

By clicking “I Agree,” I acknowledge that I have read and understand the terms presented below, understand the risks and benefits of telehealth, including asynchronous telemedicine where offered, and hereby give my informed consent to participate in telehealth Clinical Services through the Platform under these terms.

The following terms apply throughout this Consent and are intended to align with the definitions used in RespondWell’s Terms of Use:

• Platform: RespondWell’s websites, applications, intake forms, messaging tools, scheduling tools, and related services.

• Clinical Services: Medical evaluation, diagnosis, treatment, follow-up, and prescribing provided by licensed clinicians.

• Provider: A licensed clinician (e.g., physician, nurse practitioner, physician assistant) providing Clinical Services.

• Practice / Medical Group: The professional entity through which Providers furnish Clinical Services. As of the effective date of this Consent, Clinical Services are furnished through Wasef Health, P.C. (“Wasef”). RespondWell may make Clinical Services available through additional Practices from time to time; this Consent applies to Clinical Services furnished by any Practice through the Platform.

Telemedicine, also referred to as telehealth, is the delivery of healthcare services—including evaluation, consultation, diagnosis, treatment, follow-up, care coordination, and patient education—through electronic communication technologies when you and your healthcare practitioner are not in the same physical location.

Telehealth can make care more accessible by allowing you to submit health information remotely and receive care without traveling to a physical office in every instance.

Asynchronous telemedicine is one form of telehealth. It is sometimes called “store-and-forward” communication because information is collected, submitted, reviewed, and responded to at different times rather than in a live interaction.

Examples of asynchronous telemedicine may include submission of health questionnaires, photographs, video, messages, medication histories, and other health-related information for later review by a healthcare practitioner. This differs from synchronous telemedicine, which generally involves real-time audio or video interaction between you and your healthcare practitioner.

The Platform may support asynchronous telemedicine tools, including secure intake forms, questionnaires, messaging, image submission, and other store-and-forward communications. In some cases, synchronous communications such as phone, audio, or video may also be used where appropriate.

As with any medical service, there are potential risks associated with telehealth, including asynchronous telemedicine. These risks may include, without limitation:

• delays in medical evaluation, consultation, or treatment due to technology failures, service interruptions, poor data quality, internet outages, platform outages, or other technical issues;

• unauthorized access to, or compromise of, personal or medical information despite reasonable security safeguards;

• misunderstanding or incomplete evaluation if the information you submit is inaccurate, incomplete, delayed, or does not fully reflect your condition;

• inability of the treating provider to perform certain aspects of an in-person physical examination, which may limit diagnostic accuracy or make telehealth inappropriate for certain conditions;

• adverse treatment outcomes, allergic reactions, medication interactions, or other negative outcomes if you fail to provide complete and accurate information regarding your symptoms, medical history, medications, supplements, allergies, or prior treatment; and

• the possibility that telehealth may be determined by the treating provider to be inappropriate for your condition, requiring an in-person visit, additional testing, or referral elsewhere.

Telehealth services are not emergency services, and communications submitted through the Platform are not monitored 24/7. If you believe you are experiencing a medical emergency, call 911 immediately or seek appropriate emergency care.

The care you receive will be at the sole discretion of the healthcare practitioner treating you. There is no guarantee of diagnosis, treatment, or prescription. The treating provider will determine whether the condition being diagnosed and/or treated is appropriate for care delivered through telehealth, including asynchronous telemedicine where applicable.

You understand that Providers affiliated with your Practice may, in their professional judgment, recommend or prescribe FDA-approved medications or devices for a use that differs from the use specifically approved by the FDA. This is sometimes referred to as “off-label” use. You understand that you have the right to ask questions about, and to refuse, any medication, device, or treatment recommended to you.

You also understand that Providers affiliated with your Practice may, where clinically appropriate and legally permitted, prescribe compounded drug products. Compounding is a practice in which a licensed pharmacy combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient. Compounded drugs are not FDA-approved. This means that neither the FDA nor any other regulatory body tests, evaluates, or studies compounded medications as finished products for safety, effectiveness, or quality. You understand that you have the right to ask questions about, and to refuse, any compounded medication recommended or prescribed to you.

By using the Services and agreeing to this Consent, you acknowledge and agree that:

• telehealth may involve the electronic collection, use, storage, and transmission of your medical and personal information among RespondWell, your Practice, your Provider, and service providers such as laboratories and pharmacies, as reasonably necessary to provide and facilitate your care;

• the treating provider may be located in a different city, county, or state than you, provided the provider is licensed or otherwise authorized to provide care to you where required by applicable law;

• you have the right to ask questions about telehealth services, including available alternatives, and may decline telehealth services at any time before treatment is provided, subject to applicable law and platform limitations;

• you understand that the anticipated benefits of telehealth cannot be guaranteed, and no particular result is promised or assured;

• information you submit through the Platform, and information documented by your Provider, may become part of your medical record and will be maintained by your Practice and/or its service providers in accordance with applicable law;

• you are responsible for providing truthful, accurate, and complete information and for updating that information if it changes;

• you are responsible for complete and timely payment of all fees. Continued access to certain Platform features, consultations, prescriptions, or other Services may be delayed, limited, or unavailable if payment is not successfully authorized, captured, or maintained.

• the treating provider may determine, in the provider’s sole professional judgment, that your condition is not appropriate for telehealth or asynchronous care and may require an in-person evaluation, laboratory testing, emergency care, or referral to another provider;

• you may withdraw your consent to future telehealth services at any time by discontinuing use of the Platform and contacting your Practice or RespondWell support, although withdrawal will not affect actions already taken in reliance on your prior consent; and

• your health information may be used and disclosed as described in the applicable Notice of Privacy Practices, Privacy Policy, and as otherwise permitted or required by law.

You further understand that your healthcare information may be disclosed without your authorization where permitted or required by law, including, for example:

• when required by a valid court order, subpoena, or other lawful process;

• for reporting suspected abuse, neglect, or domestic violence, where required by law;

• to prevent or lessen a serious and imminent threat to health or safety, where permitted by law; and

• for public health, regulatory, health oversight, or law enforcement purposes, where permitted or required by law.

You expressly consent to allow RespondWell, your Practice, and their Providers, contractors, and service providers to call, email, or text you, including via SMS and/or MMS, regarding your account, intake, telehealth encounters, prescriptions, refill reminders, orders, shipping, billing, care coordination, and similar matters related to the Services, using the contact information you have provided.

Any calls or texts to you may be placed using an autodialer or a prerecorded or artificial voice, where permitted by applicable law, even if your number is on a do-not-call list. Your phone carrier’s normal message and data rates may apply. This consent is not a condition of purchase where prohibited by law. You may revoke consent to receive promotional or other non-essential communications at any time by following the instructions in the communication or contacting us. However, you understand that transactional, operational, account, and healthcare-related communications may still be sent to you as necessary to provide the Services and facilitate your care.

You understand and agree that the Services are not intended for emergency or urgent situations requiring immediate attention. If you are experiencing a medical emergency, call 911 immediately or go to the nearest emergency room.

Clinical Services are provided by independent licensed clinicians through the following Practice(s) / Medical Group(s). RespondWell is a technology platform only and is not a medical provider.

Wasef Health, P.C.

5260 78th Ave N, PO Box 1697

Pinellas Park, FL 33780

[email protected]

RespondWell may add or change affiliated Practices from time to time. An updated list of associated Practices will be made available on the Platform. Continued use of the Platform following any such update constitutes your acknowledgment of the change.

This Consent to Telehealth remains effective during your treatment through your Practice and your use of the Platform unless and until you withdraw your consent as described above, subject to applicable law.