DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY.

In an emergent situation, you can:

• (i) call 911;

• (ii) go to the nearest emergency room;

• (iii) contact your local crisis center;

• (iv) if applicable, call the National Suicide Prevention Lifeline 988; or

• (v) if applicable, contact the Crisis Text Line (text “HOME” to 741-741).

Thank you for choosing Bask Health Inc. (Bask) and Wasef Health, PC. You are viewing this form because you have elected to engage in asynchronous telemedicine visits with a Wasef Health, PC healthcare practitioner via Bask. 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 OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN ASYNCHRONOUS TELEMEDICINE UNDER THESE TERMS.

Note that, as indicated in our Terms of Use, Only Human RX is not a healthcare provider or medical practice. Always directly contact your provider or other qualified healthcare professionals with any questions regarding your personal health or medical conditions. Any such telehealth medical advice shall be governed by this Informed Consent. If any medical advice is provided to you by a provider from a Partner Practice, such medical advice is not provided by Only Human RX but is provided by that provider. This document is intended to inform you of what you can expect of your telehealth provider in terms of his or her credentials and in connection with your treatment via telehealth. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

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 Health, PC 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 Health, PC 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 Health, PC 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 Health, PC 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 Health, PC 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.

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 Health, PC Privacy Policy.

SCHEDULING AND CANCELLATIONS. Please carefully review the Scheduling and Cancellations Policy. By signing this document, you are attesting that you have read, understood and will comply with the Scheduling and Cancellations Policy.

FEES AND BILLING ARRANGEMENTS. Prices are subject to change. You are required to pay all fees for your telehealth services upfront at the time of services. All services are cash-pay only and Only Human RX does not accept insurance or bill any governmental payors (like Medicaid or Medicare). If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within 10-15 calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why).

You hereby consent to receiving the services via telehealth technologies. You understand that Only Human RX and its providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor. You also understand it is up to the Only Human RX provider to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.

1. You have been given an opportunity to select a provider from Only Human RX prior to the consult, including a review of the provider’s credentials.

2. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Only Human RX will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.

3. You understand there is a risk of technical failures during the telehealth encounter beyond the control of Only Human RX. You agree to hold harmless Only Human RX for delays in evaluation or for information lost due to such technical failures.

4. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that the Only Human RX providers are not able to connect you directly to any local emergency services.

5. You understand that alternatives to telehealth consultation, such as in-person services are available to you, and in choosing to participate in a telehealth consultation, you understand that some parts of the services involving tests may be conducted by individuals at your location, or at a testing facility, at the direction of the Only Human RX provider (e.g., labs or bloodwork).

6. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.

7. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Only Human RX provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the consultation and thus will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.

8. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.

9. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.

• 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 Health, PC via text message and entered by your healthcare practitioner in the Wasef Health, PC 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 Health, PC 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 Health, PC Privacy Policy and regulations or laws in 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.

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 Health, PC 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.

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