Purpose: The purpose of this form is to obtain your consent to participate in a Telehealth Consultation/Treatmentwith Virtuous Wellness Center in connection with the following procedure(s) and/ or service(s).

1. Nature of Telehealth Consult: During the telehealth consultation:

a. Details of your medical history, examinations, x-rays, and tests will be discussed with other health careprofessionals using interactive video, audio, and telecommunicationtechnology.

b. A digital physical examination may take place.

c. A non-medical technician may be present in the telehealth studio to aid in the videotransmission.

d. Video, audio and/ or photo recording may be taken of you during the procedure(s) orservice(s) fortreatment purposes only.

1. Medical information & Records: All existing laws regarding your success to medical informationand copies ofyour medical records apply to this telehealth consultation. Please note, not all telecommunications arerecorded and stored. Additionally, dissemination of any patient identifiable images or information for thistelehealth interaction to any other parties or entitles shall not occur without your consent.

2. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidential risksassociated with telehealth consultation, and all existing confidentially protections under state and federallaw apply to information disclosed during this telehealthconsultation.

3. Rights: You may withhold or withdraw your consent to the telehealth consultation at any time without affecting your right to future care or treatment.

4. Risks, Consequences & Benefits: You have been advised of all potential risks, consequences, and benefits of telehealth. Your health care provider has discussed with you the information provided above.

TeleHealth Patient Consent Form

(410) 975-5343