Telehealth Consent

Telehealth Informed Consent & Disclosure

I understand that Mavrox has arranged a telehealth consultation for me and an independent and duly licensed medical provider (the "Provider") utilizing its telehealth platform. There are two primary methods for such telehealth consultations:

Asynchronous Consultation

I may be able to conduct an asynchronous telehealth consultation, in which I will provide the requisite personal health information to my Provider in a digital format. Based on that health information, my Provider may be able to diagnose and prescribe treatment upon review of the information that I have provided. I acknowledge, however, that I may not be a good candidate for asynchronous consultations and that either the Provider or Mavrox may require that I engage in a live, interactive video consultation with the Provider prior to beginning any treatment.

Live Video Consultation

If required to conduct — or if I choose to conduct — an interactive video consultation with my Provider, I will be able to consult with the Provider about my health and wellness concerns in real time via a live video connection through the Mavrox platform.

Mavrox has explained to me how telehealth will be used to do such consultation and how else we will use telehealth to connect with the Provider while working together, utilizing the telehealth platform.

Potential Risks

I understand there are potential risks with this technology:

• The video connection may not work or it may stop working during the consultation.
• The video picture or information transmitted may not be clear enough to be useful for the consultation.
• My personal health information may be misreported or inaccurately stored, making asynchronous or live video consultations difficult, inaccurate, or impossible. I acknowledge that I have an obligation to accurately and truthfully present my personal health information to Mavrox and the Provider, and that any treatment provided based on inaccurate information will be my sole responsibility and liability.

Benefits of Telehealth

• I do not need to travel to the consult location.
• I can meet with a provider quickly and efficiently.
• I have access to a specialist Provider through this consultation.

I also understand other individuals may need to use the telehealth platform and that they will take all reasonable and necessary steps to maintain confidentiality of the information I provide. I have read this document and understand the risk and benefits of the telehealth consultation, and have had my questions regarding the procedure explained. I hereby consent to participate in telehealth sessions under the conditions described in this document.

Terms of Treatment

I have further read and agreed to the terms below in association with my telehealth sessions and treatment with and through my Provider and Mavrox.

Accurate Information

A member of my Provider team assessed my medical condition and made a clinical treatment determination, taking into account the information I provided. If I forgot to provide or incorrectly provided certain information related to my health, there is a possibility that the Provider may misdiagnose or fail to diagnose conditions that I may have, which could affect their recommendation for treatment. If I need to clarify or update any information about my health, I must contact the member success team or meet with my licensed Provider through a follow-up form or virtual appointment on the Mavrox platform as soon as possible.