CONSENT FOR LIMITED ONLINE WEIGHT LOSS TREATMENT AND

ACKNOWLEDGMENT OF LIMITED PHYSICIAN-PATIENT RELATIONSHIP

Patient Name: _______________________________________________________________________________
Date of Birth:___________________________________ Gender: ____________________________________
I hereby authorize Middlebelt Medical Center, P.L.C., d/b/a as Virtual Weight Management, its subsidiaries/affiliated/contracted entities (“Company”), and its related and/or contracted physicians, other health care professionals, employees, and contractors (the “Professionals”),* to use telehealth** in the course of my limited diagnosis and treatment related to weight loss utilizing the Company’s proprietary system, methods, and protocols (the “Weight Loss Services”). I HEREBY REQUEST AND CONSENT TO THE ONLINE WEIGHT LOSS SERVICES TO BE PROVIDED BY COMPANY AND THE COMPANY PARTIES. I understand that telehealth involves the communication of my medical information, both orally, in writing, and visually, to physicians and other healthcare practitioners at other locations. I understand that the physician-patient relationship, if any, between myself, Company, and the Treating Professionals, is explicitly limited in nature to the Weight Loss Services, and nothing else. I further understand that, even if I have health insurance of any form, that the Consultation Services are private-pay and are likely not coverable by such insurance. I agree to NOT bill any insurer that may cover me for the Weight Loss Services, and acknowledge that Company and the Professionals will not be billing any 3^rd party for the Consultation Services.

Weight Loss Services Specifically

1. PREGNANCY AND BREASTFEEDING: I UNDERSTAND THAT IF I AM PLANNING TO BECOME PREGNANT, AM CURRENTLY PREGNANT, BECOME PREGNANT, OR AM BREASTFEEDING, THAT I WILL: (A) ADVISE COMPANY AND THE COMPANY PARTIES OF THIS; AND (B) ASK MY OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE COMPANY PARTIES ARE ACCEPTABLE DURING THIS PERIOD OF TIME.
2. OUTCOMES NOT GUARANTEED:  Neither Company nor the Professionals guaranty outcomes based on utilizing the Weight Loss Services or products or medicines associated with the Weight Loss Services. I acknowledge that my condition for which I am seeking treatment may get worse, and I am subject to the risks further described below, including risks that my condition may worsen. I agree that I will not be entitled to a refund or recompense from Company or the Professionals for any reason, including poor outcomes.
3. Company Does Not Provide or Pay For Prescribed/Recommended Medicines, Products, or Other Courses of Treatments: I understand that the fees that I pay Company and/or the Professionals DO NOT include the costs of any prescription drugs or medicines, or other courses of treatment, that may be recommended/prescribed by Company or the Professionals. I understand that I am wholly responsible for the payment of any such products, drugs or medicines or treatments.
4. I understand that all health care treatments can have potential adverse side effects and I accept responsibility for these potential adverse outcomes.
5. If adverse effects are noted, I understand that it is my responsibility to stop all treatments recommended by the Professionals, and to report any adverse side-effects to Company, the Professionals, my local doctor, and to go to the nearest Emergency Room if necessary.
6. I understand that it is my responsibility to contact my local primary care physician before starting any treatments, prescriptions,*** or implementing any Professionals’ Weight Loss Services suggestions, to make sure that my local doctor approves of the treatment regimen.
7. I understand that once the Professionals decide on the treatments and medications to be issued, if any, it is my responsibility to read and understand the risks and the side-effect profile of the medications and the adverse drug interactions of the medications and other medications I may be taking, to consult with my local doctor and pharmacist regarding the same, and ultimately to determine if the risks are acceptable to me.

Limited Nature of Relationship

1. I understand that I should not expect any services from Company or the Professionals outside of the limited Weight Loss Services.
2. I UNDERSTAND THAT COMPANY AND THE COMPANY PARTIES ARE NOT MY GENERAL OR SPECIALIZED PHYSICIANS/HEALTH CARE PROVIDERS, AND ARE ENGAGED FOR A LIMITED PURPOSE, AND I UNDERSTAND THAT I SHOULD FOLLOW-UP WITH MY PRIMARY CARE PHYSICIAN REGARDING ANY ISSUES THAT MAY ARISE DURING THE WEIGHT LOSS SERVICES.
3. TO THE EXTENT ALLOWABLE BY LAW, THE WEIGHT LOSS SERVICES ARE NOT INTENDED TO CREATE, NOR DO THEY CREATE, ANY PHYSICIAN-PATIENT RELATIONSHIP WITH COMPANY OR THE COMPANY PARTIES, EXCEPT FOR THE LIMITED PURPOSES OF PROVIDING WEIGHT LOSS SERVICES. I EXPRESSLY AGREE THAT THIS IS A LIMITED ENGAGEMENT. I EXPRESSLY AGREE THAT NEITHER COMPANY NOR THE COMPANY PARTIES HAS AN OBLIGATION TO TREAT ME OR OTHERWISE COUNSEL ME REGARDING ANY CONDITIONS THAT MAY BE DISCOVERED OR EVALUATED OR DISCUSSED DURING THE CONSULTATION SERVICES. I UNDERSTAND THAT THE COMPANY AND THE COMPANY PARTIES DO NOT GUARANTEE THE ACCURACY, COMPLETENESS, USEFULNESS, OR ADEQUACY OF THE WEIGHT LOSS SERVICES FOR ANY TREATMENT, DIAGNOSIS, OR OTHER PURPOSES.
4. I WILL INFORM COMPANY AND THE COMPANY PARTIES OF ANY CONDITION THAT WOULD LIMIT MY ABILITY TO HAVE WEIGHT LOSS SERVICES OR THAT WOULD BE RELEVANT TO THE WEIGHT LOSS SERVICES ITSELF.

Telehealth

1. I understand that while the Professionals will make every attempt to accurately diagnose and treat my healthcare condition for which I am seeking a second opinion, there is still some inherent uncertainty and inaccuracy with delivering healthcare over the Internet.  I accept that the “physical exam” portion of the online visits, if any, will be done via pictures, two-way audio/video consultation, questionnaire, relying upon my medical records, or otherwise, which  agreed to be an appropriate prior examination made in good faith, though, in some other types of medical situations, such a methodology is not a “conventional” way of conducting a physical examination.  I accept this, with all potential benefits and consequences, and deem this method of physical examination appropriate and complete.
2. I understand that I have the option to withhold or withdraw my consent to receive the Weight Loss Services via telehealth at any time, but that doing so will cause Company and the Professionals to discontinue providing future care or treatment, it being acknowledged that Company and the Professionals will only be treating me via telehealth methodologies. In such case, I understand that I will need to seek treatment elsewhere.
3. I understand the potential benefits of telehealth, which include having access to medical specialists and additional medical information and education without having to travel outside of my local health care community.
4. I understand the potential risks and consequences of telehealth, which include that because of my specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment, and the telehealth care provider may not be able to accurately diagnose my condition due to limitations inherent in using a non-face-to-face encounter. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.
5. I understand that all laws about the confidentiality of medical information apply to telehealth information.
6. I understand that all laws about patient access to medical information and copies of medical records apply to telehealth records.
7. I understand that no images or information from the telehealth interaction that identify me will be given to researchers or other entities or parties not listed above without my consent, unless allowed by applicable law.

I have read and understand the written information provided above. I agree that the information provided above adequately explains the Weight Loss Services to me, along with the risks and benefits of said Weight Loss Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full by Company, the Professionals, and/or their designees. By electronically signing this form, I acknowledge and agree to all of the above, and certify that I have no questions and/or have had my questions answered in full.

Further, I represent that I have read and fully understood and agreed to: (i) the Company Private Pay Agreement; (ii) the Company Notice of Medical Information Privacy Practices; (iii) the Company Website Privacy Policy; and (iv) the Company Website Terms of Use.  [CM1]

By electronically signing below, I am agreeing to conduct transactions electronically, and intend for my electronic signature to be a binding electronic signature/contractual obligation. Further, Patient understands and acknowledges that they are digitally receiving a copy of this Agreement concurrently with executing the Agreement, in that Patient has the ability to print and/or retain a copy of this Agreement.

THIS FORM MUST BE PLACED IN THE MEDICAL RECORD.

A COPY MAY BE GIVEN TO THE PATIENT.

*Company may not be the provider of medical services; medical treatment may be provided to Company users utilizing a separate entity or other Professionals who are medical professionals. **“Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care  provider is at a distant site.  Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers. ***Online prescriptions will only be issued when indicated and approved by a physician, and as permitted by law in your state.

4822-4212-7894, v.  2