Telehealth Consent Form – Sapphire RX

1. Purpose of This Consent

This form explains your rights and responsibilities when receiving telehealth services from licensed medical providers affiliated with MD Integrations through the Sapphire RX platform. By submitting your information, you consent to receive care via telemedicine instead of in-person visits.

2. What Telehealth Includes

Telehealth may include: - Review of your intake forms, labs, and medical records - Video, phone, or secure message consultations - Prescription of medications (e.g., GLP-1s, NAD+, others) - Referral to local specialists if medically necessary

3. Your Rights

You have the right to: - Be treated with dignity and respect - Ask questions and receive clear answers - Refuse or withdraw telehealth consent at any time - Request copies of your medical records - Know the identity and credentials of your provider

4. Risks and Limitations

Telehealth has limitations, including: - Limited physical exam, which may affect accuracy - Delayed communication or technical failures - Possible need for in-person follow-up - Not all conditions may be treatable remotely - Your provider may determine telehealth is not appropriate for your needs

5. Confidentiality and Privacy

Your health information may be shared with MD Integrations providers, pharmacy partners including The Pharmacy Hub, labs, and HIPAA-compliant vendors. All communications are encrypted. Use a secure device and private location during your consult. Do not share login credentials.

6. Emergencies

Sapphire RX does not provide emergency care. If you experience a medical emergency, call 911 or go to the nearest emergency room. Do not rely on this platform for urgent or life-threatening conditions.

7. Patient Responsibility

You agree that: - You are at least 18 years old - You have provided complete, truthful information - You will update Sapphire RX if your health status changes - You understand false information may result in denial or termination of services

8. Consent Acknowledgment

By signing, you confirm: - You understand the purpose, benefits, and risks of telehealth - All questions have been answered - You voluntarily consent to receive care via telehealth - This consent applies to all care provided through Sapphire RX and MD Integrations

9. Limitation of Liability

Sapphire RX is not liable for technology failures, communication delays, or failure to seek emergency care. Our total liability is limited to the fees you paid in the past 12 months.

10. Telehealth Arbitration

All non-medical disputes related to telehealth services will be resolved through binding arbitration administered by the American Arbitration Association in Davidson County, Tennessee under Tennessee law. Medical malpractice claims may still be handled through state court processes. You waive your right to class actions and jury trials for all other claims.

11. Patient Indemnification

You agree to indemnify Sapphire RX for claims arising from: - False or misleading medical information you provide - Misuse of telehealth or emergency procedures - Non-compliance with treatment plans - Security breaches caused by use of unsecure devices or networks

12. Technology Requirements

You are responsible for: - Using a reliable internet connection and up-to-date browser - Accessing telehealth in a private location - Ensuring your device has a working camera and microphone - Testing your setup and having a backup method of contact