Telehealth Consent Form

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Informed Consent Regarding the use of Telehealth to Deliver Care

You understand that by checking the “agree” box for this Consent in the “intake form,” or using any other means of acceptance provided through the service or otherwise affirmatively accepting this Consent, you acknowledge that you have, read, accepted, and agreed to be bound by this Consent, and that this acceptance constitutes a legal signature.

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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 platforms owned and operated by IonLayer, Inc. (the “Service”) or its parent company.

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Terms

All capitalized terms used in this Consent to Telehealth but not defined herein have the meanings assigned to them in the Terms of Service. For avoidance of any doubt, the terms “ion“, “IonLayer”, “we“, “us“, or “our” refer to ion layer, Inc and the terms “you” and “yours” refer to the person using the Service.

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Telehealth

IonLayer, Inc. does not provide medical or healthcare services, including via the Sites and Services. IonLayer provides a platform to facilitate a consultation between affiliated Providers and you. The Consent to Telehealth services is between you and the Providers, MDI located at 447 Rose Ln, Rockville Centre, NY 11570.

Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or sub-specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

- Patient medical records

- Medical images

- Live two-way audio and video and data communications

- Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Possible Benefits of Telehealth:

- Improved access to medical care

- More efficient medical evaluation and management

- Possibility of selecting a time that is convenient to you

- Possibility to choose a location that is convenient for you

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Possible Risks of Telehealth

As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to:

- Provider may not be able to provide medical treatment for your particular conditions;

- Regulatory requirements may limit your providers ability to provide treatment options, including prescriptions;

- Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment;

- Security protocols could fail, resulting in privacy breaches of personal medical information;

By accepting this agreement, I understand the following:

1. I have read and understand the information provided above regarding the benefits and risks of Telehealth provided to me for medical care and treatment by Providers to whom I’ll be connected through IonLayer’s platform, and that ion layer does not itself provide medical care or treatment.
2. I give my informed consent to the use of Telehealth by providers affiliated with IonLayer.
3. I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth.
4. I understand that I have the right to withhold or withdraw my consent to the use of Telehealth in the course of my care at any time by emailing IonLayer with such instruction.
5. This consent will be renewed upon further consultations, unless I explicitly withdraw consent over email.
6. I understand that I have the right to inspect all information obtained and recorded in the course of a Telehealth interaction, and may receive copies of this information for a reasonable fee
7. I understand that I may expect the anticipated benefits from the use of Telehealth in my care, but that no results can be guaranteed or assured.
8. I understand the Provider may determine that a Telehealth consultation is not suitable for me.
9. I authorize the health care Provider to share information about my Telehealth consultation and exam with others for treatment, payment, and healthcare operations.
10. I authorize the healthcare Provider to release information regarding my consultation and exam to its affiliates.
11. I consent to receive emails or other electronic communications from IonLayer, Inc. and its affiliated Providers pertaining to my care from the Providers, which may include Protected Health Information, and that not all such modern electronic communications are end-to-end encrypted, such as SMS (text messaging).

Last updated: November 7, 2022

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