MD CONNECTED LTD. TELEHEALTH ACKNOWLEDGEMENT

NEVER REQUEST AN ELECTRONIC VISIT FOR AN URGENT MEDICAL PROBLEM, CALL 911 INSTEAD.

I hereby consent to engaging in telemedicine e-visits with an MD Connected Service Provider. I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data and education using interactive audio, video or other electronic data communications. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone or online chat. These methods are by their very nature not as secure as a face-to-face encounter. Further, I agree that the Service Provider may use unencrypted email services to communicate any of my medicine prescriptions to my pharmacist. Lastly, I agree that the Service Provider may use unencrypted email services to communicate with me and to send materials and documents to me using such form of communication.

I understand that the laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my treatment is confidential. I further understand that there are risks and consequences associated with telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my Service Provider, that, the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. By requesting an e-visit, I acknowledge and agree that personal health information will be communicated in a manner that is subject to hacking and other malicious behaviour.

As with any medical service, decision, or treatment, there are risks. Because this visit is electronic and not face-to-face, I acknowledge and agree that the risk may be greater than a traditional face-to-face visit, and by requesting the e-visit I agree to accept the outcome, even if it is undesirable.

I understand that telemedicine based services and care may not be as complete as face-to-face services. Finally, I understand that there are potential risks associated with any form of medical treatment, and that despite the efforts of my Service Provider, my condition may not improve, and in some cases may even get worse. Therefore, I understand that while I may benefit from telemedicine, results cannot be guaranteed or assured.

I also understand that if my Service Provider believes I would be better served by another form of medical services (for example, face-to-face services) I will be advised to visit a medical services provider who can provide such services.

I understand that prior to the e-visit, I may be asked to complete certain medical questionnaires. Sometimes, after reviewing my information, or during the e-visit it may be determined (in MD Connected’s sole discretion) that my problem is too complex for an e-visit session. In that case MD Connected will not accept my appointment and advise me to visit a medical services provider who can provide such services.

I have read and understand the information provided above.