Consent to Telehealth

Thank you for choosing Wasef Health, P.A. ("Wasef")! You are viewing this form because you have elected to engage in asynchronous telemedicine visits with a Wasef healthcare practitioner. Your practitioner is a board-certified physician licensed in your state.

By clicking "I Agree," I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF ASYNCHRONOUS TELEMEDICINE, AND BY ACCEPTING THESE TERMS I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN ASYNCHRONOUS TELEMEDICINE UNDER THESE TERMS.

What is Telemedicine?

Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. Wasef allows you to receive treatment from a healthcare practitioner without having to travel to another location or schedule a separate appointment and helps you avoid long wait times that you might otherwise experience at an in-person visit.

What is Asynchronous Telemedicine?

Asynchronous telemedicine is one way to deliver telemedicine. Asynchronous communication is often referred to as "store-and-forward" communication, where participants submit and collect data at different times. An example of asynchronous communication is a telemedicine encounter with a healthcare practitioner that involves sending photos, video, or other communications via email or text message. "Asynchronous" means "not occurring at the same time" and is different from "synchronous" telemedicine, which generally includes visits conducted in real-time between patients and healthcare practitioners through audio or video means (e.g., live phone calls or video-conferencing). Healthcare practitioners may use asynchronous telemedicine to aid in diagnoses and medical consultations when live communication or face-to-face contact is not possible or necessary.

Wasef's platform ("Platform"), in particular, allows for the following asynchronous telemedicine services: 1) text-based healthcare practitioner-patient interactions through short message service ("SMS") and multimedia messaging service ("MMS") communications; and 2) secure information collection through asynchronous store-and-forward patient questionnaires.

What are the Possible Risks to Using Asynchronous Telemedicine?

As with any medical treatment, there are potential risks associated with the use of asynchronous telemedicine. Wasef believes that the likelihood of these risks materializing is very low. These risks may include, without limitation, the following:

Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur.

Security protocols could fail, causing a breach of privacy of personal medical information.

Because Wasef does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur.

Asynchronous telemedicine services are NOT emergency services and your Personal Data (as defined in the Wasef Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR THE CARE PROVIDED THROUGH AN ASYNCHRONOUS TELEMEDICINE ENCOUNTER VIA THE PLATFORM.

Consent for Compounded Medications

If you receive a prescription for a compounded medication through the Platform, you understand and agree to the following:

The FDA does not approve nor review compounded products for safety, effectiveness, or quality.

Compounding pharmacies must adhere to strict quality control standards to ensure the safety and effectiveness of the medications they prepare. Compounding pharmacies are licensed pharmacies subject to state and federal regulations.

You have been given the opportunity to ask questions about your compounded medication and those questions have been answered to your satisfaction.

Your Rights and Acknowledgements

You have the same privacy rights via asynchronous telemedicine that you would have during an in-person visit. Dissemination of any identifiable images or information from the asynchronous telemedicine visit to researchers or other entities will not occur without your written consent. For more information about how we protect your privacy, please read the Wasef Privacy Policy.

Asynchronous telemedicine may involve electronic communication of your personal medical information to healthcare practitioners who may be located in other areas, including out of state.

You understand that you may expect the anticipated benefits from the use of asynchronous telemedicine, but that no results can be guaranteed or assured.

You understand that all information submitted to Wasef via text message and entered by your healthcare practitioner in the Wasef Platform will be part of your medical record and available to you by emailing contact@wasef-health.com. This information will have the same restrictions on dissemination without your consent.

You understand that your healthcare practitioner's initial text message to you will include his/her name and credentials, and this will be recorded in the Wasef Platform as part of your medical record.

You understand you may withdraw your consent and delete your patient profile at any time by emailing contact@wasef-health.com.

You understand that your healthcare information may be shared with other individuals in accordance with the Wasef Privacy Policy and regulations or laws in the state or territory in which you are located.

You further understand that your healthcare information may be shared in the following circumstances:

When a valid court order is issued for medical records.

Reporting suspected abuse, neglect, or domestic violence.

Preventing or reducing a serious threat to anyone's health or safety.

You understand that you are responsible for payment of any amounts due and owing resulting from your telehealth visit.

You understand that participating in a telehealth visit is not a guarantee that you will be given a prescription, and that the decision as to whether a prescription is appropriate for your condition will be made in the professional judgment of your Provider.

You understand that Providers do not address medical emergencies via the Platform. In an emergency, your Provider's responsibility may be to direct you to emergency medical services.

You agree that any information you provide as part of any telehealth visit is accurate, true, and complete.

Authorization to Use and Disclose Protected Health Information

I understand and agree that I give permission to Providers to use and disclose my protected health information including my entire medical record. This protected health information is being used or disclosed for the purpose of telehealth treatment. This authorization expires when you contact help@glp-1.com.

If the person or entity receiving this information is not a health care provider or health plan covered by HIPAA, the information described above may be redisclosed to other individuals or institutions and therefore no longer protected by HIPAA.

I may refuse to agree to this authorization. My refusal to sign will not affect my payment, ability to obtain treatment, or eligibility for health plan benefits.

I may inspect or copy the protected health information to be used or disclosed under this authorization.

I may revoke this authorization in writing at any time by sending a written notification to our Privacy Officer at:

GLP-1 Strategic Holdings LLC30 N Gould St Ste R, Sheridan, WY 82801help@glp-1.com

Call/Email/Text Messaging Consent

You expressly consent to allow Wasef or its healthcare practitioners to call, email, or text you (via SMS and/or MMS) with or regarding Personal Data (as defined in the Wasef Privacy Policy), appointments, or similar matters related to your telemedicine encounters using the contact information you have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier's normal rates may apply. This is consent, not a condition of purchase. You may revoke this consent at any time by emailing us at contact@wasef-health.com.

SMS Consent

By using our services, you agree to receive text messages in regards to the customer care services provided to you by GLP-1 Strategic Holdings LLC. This will be supplementary to other methods of communications about your services and is not a requirement in order to receive the services. Message and data rates may apply. You can always text STOP to discontinue receiving messages, and START to resubscribe.

This Asynchronous Telemedicine Informed Consent is valid during your entire treatment with Wasef.