WORKIT HEALTH CLINIC INFORMED CONSENT FOR TELEHEALTH, TREATMENT, AND PRESCRIPTION OF CONTROLLED SUBSTANCES (the “Consent”)

PLEASE CAREFULLY REVIEW THIS CONSENT. IT PROVIDES INFORMATION REGARDING POSSIBLE BENEFITS AND RISKS ASSOCIATED WITH RECEIVING TELEHEALTH, TREATMENT, AND PRESCRIPTIONS THROUGH A WORKIT HEALTH CLINIC.

Overview

You are receiving this Consent because your Workit Health Clinic is recommending that you engage in certain treatment (as more fully set forth in this Consent) that may involve induction, drug testing, telehealth, and the prescribing of certain controlled substances and other medications. A “Workit Health Clinic” includes Workit Health (MI) PLLC; Workit Health (CA), P.C.; Workit Health (NJ), LLC; Workit Health (OH), LLC; A.M. Physician Practice (NY), PLLC; and any other Workit Health professional entity that is established in the future.

The treatment and medication outlined in this Consent has known possible risks that you need to understand before making a decision to engage in the treatment or to use any medications. Each Workit Health Clinic and its providers want you to completely understand your treatment and medications and any risks or benefits associated with engaging in, not engaging in, or abruptly stopping, the treatment or authorized use of any prescribed medications.

While we strive to provide you with comprehensive information regarding treatment and medication options, you understand that not every option and its possible risks and benefits can be listed on this Consent, and that this Consent only describes the most common risks, side effects or reactions.

By signing this Consent, you acknowledge that a Workit Health Clinic provider or clinician (or designee) has explained to you all of the following or that you have read, understood, and had the opportunity to ask questions regarding all of the following.

Information Regarding Telehealth

The treatment provided to you by your Workit Health Clinic provider will be delivered primarily or solely through telehealth. Telehealth involves the delivery of health care/medical services using electronic communications, information technology or other means between a health care provider and an individual who are not in the same physical location. Telehealth can occur asynchronously, through two-way interactive audio in combination with store-and-forward communications, and/or through two-way interactive audio and video interaction.

The electronic systems used in telehealth will incorporate network and software security protocols to protect the privacy and security of your information, including, but not limited to, encryption, password protection, two-factor authentication, and other reliable authentication techniques, and will include measures to safeguard data to ensure its integrity against intentional or unintentional corruption. Telehealth may be used to document your medical history, schedule appointments, perform an exam, or for diagnosis, treatment, follow-up and/or patient education, and may include one or more of the following:

• Electronic transmission of medical records, photo images, personal medical information or other data between you and your Workit Health Clinic provider;
• Interactions between you and your Workit Health Clinic provider via audio, video and/or data communications (such as chat); and
• Use of output data from medical devices, sound and video files.

Possible Benefits of Telehealth

The use of telehealth by the Workit Health Clinic provider may have the following benefits:

• Making it easier and more efficient for you to access medical care and treatment for the conditions treated by your Workit Health Clinic provider;
• Allowing you to obtain health care/medical care and treatment from your Workit Health Clinic provider at times that are convenient for you; and
• Enabling you to interact with your Workit Health Clinic provider without the necessity of an in-office appointment.

Possible Risks of Telehealth

While the use of telehealth can provide potential benefits for you, there are also potential risks associated with the use of telehealth. These risks include, but may not be limited to, the following:

• The information transmitted to your Workit Health Clinic provider may be insufficient (e.g., poor resolution of images) to allow for appropriate medical decision-making by the Workit Health Clinic provider;
• The inability of your Workit Health Clinic provider to conduct certain tests or assess vital signs in-person may in some cases prevent your Workit Health Clinic provider from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you;
• Your Workit Health Clinic provider may not be able to provide medical treatment for your particular condition and you may be required to seek alternative health care or emergency care services;
• Delays in medical evaluation or treatment could occur due to unavailability of your Workit Health Clinic provider or deficiencies or failures of the technology or electronic equipment used;
• The electronic systems or other security protocols or safeguards used to provide telehealth services could fail, causing a breach of privacy of your medical or other information;
• Given regulatory requirements in certain jurisdictions, your Workit Health Clinic provider diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited; and
• A lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

Information Related to Treatment (Generally)

In addition to risks related to the use of telehealth, there are also general risks related to your receipt of treatment through the Workit Health Clinic, regardless of the type of treatment you receive. These risks include, but may not be limited to, the following:

• While the Workit Health Clinic intends to provide you with the tools to help you understand your condition more fully and to employ evidence-based treatment methods, this process may be challenging for you as we explore emotions, stress, and life change and there are no guarantees that these methods will be beneficial for you or provide temporary or permanent recovery from stimulant, opioid, or alcohol use disorder or anxiety or depression;
• Sometimes treatment identifies an underlying medical or psychological issue which may need to be addressed in a manner that the Workit Health Clinic cannot currently provide;
• The medicines that the Workit Health Clinic provider may prescribe or recommend, including over-the-counter medicines and “behind-the-counter” medicines, including controlled substances, that can cause serious side effects and adverse events that include severe allergic reaction, permanent disability, and death; and
• Adverse events related to medications can be caused by a number of factors including an allergic reaction, side effects, or interactions between a medicine that the Workit Health Clinic provider prescribes and any medical conditions you may have, other prescription medicines or other substances (e.g., supplements, herbs, over-the-counter medicines, or recreational drugs) you are taking, and your lifestyle choices such as smoking tobacco products or drinking alcohol.

Information Related to Treatment for Opioid Use Disorder, Alcohol Use Disorder, and Stimulant Use Disorder

Overview of Phases of Treatment (Induction, Stabilization, Maintenance, Tapering)

Induction (usual duration of approximately 1 week) is the first phase of treatment and involves helping patients begin the process of switching from a drug of abuse or, for example, long-acting opioids to Suboxone or another medication. Stabilization (usual duration of approximately 1 to 2 months) is the second phase of treatment and begins when the patient is experiencing no withdrawal symptoms, is experiencing minimal or no side effects, and is no longer having uncontrollable cravings for a drug of abuse. Maintenance is the third phase of treatment and may be for an indefinite duration. Under ideal circumstances, discontinuation of medication may be appropriate when a patient has achieved the maximum benefit from treatment and no longer requires continued treatment to maintain a drug-free lifestyle. Once this goal is achieved, the patient may be tapered slowly and appropriately off of the medication.

Drug and Laboratory Testing

Your Workit Health Clinic provider may ask you to undergo medical tests and examinations before and during your treatment. These tests may include random, unannounced requests for lab work (blood or urine drug screens), and other laboratory screens (such as a comprehensive metabolic panel (CMP) and HIV, Hepatitis B, or Hepatitis C screenings) during your treatment to check your general health and for drugs, and psychological evaluations if your Workit Health Clinic provider deems these necessary. These lab tests will benefit you by giving you a better idea about your health (for example, a CMP can tell you how your liver and kidneys are working) and how your medications are working during your treatment. If you refuse to have these tests done, it may not be possible to assess whether you are a good candidate for treatment, if you will have complications resulting from treatment (for example, failing to undergo appropriate lab testing could result in drug overdose, renal or liver failure, infection, or even death), or if the medication is causing any side effects or harming you and it may then no longer be safe to continue prescribing the medication.

Lab work and drug tests will often be completed through a third party such as Quest Diagnostics or LabCorp. These third parties are not affiliated with your Workit Health Clinic and your Workit Health Clinic is not responsible for any billing or fees related to the use of such third party service and is not responsible for the services you receive from these third parties. Any charges associated with using a third party service should be discussed with the third party directly or your insurance company. Your Workit Health Clinic shall hold no liability or responsibility related to any care or services received from a third party or fees or expenses incurred as a result of a third party service.

At-Home Induction

Your treatment may include at-home induction through telehealth. Risks associated with at-home induction include, but are not limited to, withdrawal, relapse, overdose, mental health issues, and medical complications. At-home induction is not comfortable or easy and you may experience withdrawal systems that vary in type and intensity. Outpatient programs carry a higher risk of relapse due to easier access to opioids and other substances and even after attempting to perform at-home induction for a brief period, your body may not be able to tolerate the same level of prescribed medications and/or other substances or combination with other medications. If you have underlying mental health issues, these issues can worsen significantly during at-home induction. Similarly, underlying medical conditions may worsen or become apparent during at-home induction. You will not experience the continuous monitoring and early intervention that you may receive at a medical detox treatment facility. We encourage you to have someone at home with you during the at-home induction. If you choose to not do so, you acknowledge that this increases some of the risks set forth above.

Controlled Substances

Your treatment may include receiving controlled substances. Controlled substances are defined by federal law and include classes of drugs such as opiates, benzodiazepines, and stimulants that may be prescribed to benefit or alleviate conditions such as pain, anxiety, depression, insomnia, muscle spasticity, convulsive disorders, and/or detoxification from opioids, alcohol, stimulants, or other substances. However, controlled substances have known risks and side effects, and can be harmful if taken without medical supervision and may lead to tolerance, physical dependence, withdrawal and/or addiction.

Possible side effects related to the use of controlled substances include nausea, vomiting, constipation, blurred vision, impaired coordination, sleepiness, and confusion, memory loss, breathing problems, fatigue, dizziness, muscle weakness, impaired ability to drive or operate machinery, personality changes, allergic reactions, overdose and fatal complications, addiction, and serious effects if used in conjunction with alcohol or other medications.

In addition, tolerance, physical dependence, withdrawal, and addiction are all possible with the use of controlled substances. Tolerance is defined as a need for a higher dose to maintain the same effect. Physical dependence is also possible, meaning that if your medication is decreased or stopped, you could experience withdrawal syndrome (including but not limited to sweating, increased heart rate and high blood pressure, insomnia, abdominal cramps, tremors, diarrhea, muscle or bone aching, and seizures). In rare cases, withdrawal symptoms may be life threatening and may require hospitalization. Addiction is recognized as when an individual abuses a drug to obtain mental numbness or euphoria, shows drug craving behavior, visits multiple doctors and pharmacies in pursuit of a medication, or demonstrates manipulative attitude towards the provider in order to obtain the drug. The medication will be tapered and discontinued if addictive behavior is observed by a Workit Health Clinic provider.

Suboxone (Buprenorphine/Naloxone)

One medication you may receive is Suboxone. Suboxone is the brand name for a specific medication combination of buprenorphine and naloxone. Suboxone is a controlled substance, schedule III (specifically, an opioid partial agonist) approved by the Food and Drug Administration (FDA) for treatment of people with opioid dependence. It can be used beneficially to help:

• Diminish the effects of physical dependence on opioids, such as withdrawal symptoms and cravings;
• Increase safety in cases of overdose; and
• Lower the potential for misuse.

Suboxone is also a very mild opiate drug that can result in physical dependence. While withdrawal is generally less intense than with heroin or methadone, if Suboxone is suddenly discontinued, you could have symptoms such as muscle aches, stomach cramps, or diarrhea. It is also possible, but rare, that you could suffer an allergic reaction (hives, rashes, and itchiness) and even more rare that you could suffer anaphylactic shock, breathing trouble, low blood pressure, or loss of consciousness. If you see these signs, you should contact a doctor immediately.

If you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of Suboxone. If you are not in withdrawal, Suboxone may cause significant opioid withdrawal. You may find that it takes several days to find the minimum dose of Suboxone that diminishes your use of the opioid you were using, experience no withdrawal symptoms, have no uncontrollable cravings for the opioid you were using, or to get used to the transition of using Suboxone. During that time, any use of other opioids may cause an increase in symptoms. After you become stabilized on Suboxone, it is expected that other opioids will have less effect.

Taking Suboxone in combination with central nervous system depressants, alcohol, or benzodiazepines, such as Valium, Xanax, Librium, Ativan, and Klonopin, may cause death by overdose. You should not take any other medication without first discussing it with your Workit Health Clinic provider. In addition, taking Suboxone with other illegal substances may increase your risk of breathing difficulties, heart problems, and sudden death. Attempts to override Suboxone by taking more opioids could result in an opioid overdose.

In addition, certain medications used to treat HIV and Hepatitis C have shown adverse effects when used in combination with Suboxone. If you are or begin treatment for these conditions, you should immediately notify your Workit Health Clinic provider.

Pregnancy and Suboxone

Pregnant women treated with Suboxone have better outcomes than pregnant women not in treatment who continue to use opioid drugs. However, there may be side effects for you and unknown side effects that could harm an unborn child including preeclampsia, miscarriage, premature delivery, opioid withdrawal symptoms (i.e., neonatal abstinence syndrome), intrauterine growth restriction, and fetal death. In addition, the delivery hospital may require babies who are exposed to opioids before birth to spend a number of days in the hospital for monitoring of withdrawal symptoms while some babies may also need medication to stop withdrawal. If you are or become pregnant, or are uncertain, you should immediately notify your Workit Health Clinic provider.

Naltrexone

Another medication you may be prescribed is naltrexone, which is a FDA approved medication to treat both opioid use disorder and alcohol use disorder. It is not an opioid, is not addictive, and does not cause withdrawal symptoms when ceasing use. However, common side effects include nausea, sleepiness, headache, dizziness, vomiting, decreased appetite, painful joints, muscle cramps, cold symptoms, trouble sleeping and toothache. More severe side effects may include liver damage or hepatitis, serious allergic reactions, pneumonia, and depressed mood. If prescribed naltrexone to treat opioid use disorder, there is a risk of opioid overdose if you try to overcome the blocking effects of the medication by taking large amounts of opioids.

Off-Label Medication

Your treatment, specifically, for stimulant use disorder, may include the prescription of off-label medications which have not been approved by the FDA to treat stimulant use disorder. “Off-label” medications are drugs that have been approved by the FDA to treat other diseases and conditions, but not stimulant use disorder; however, the FDA does not restrict providers from exercising professional judgment in prescribing off-label medications if beneficial to you. Although studies have shown that these medications can be beneficial by reducing cravings for stimulants, there are currently no FDA approved medications for the treatment of stimulant use disorder. You may be prescribed medication(s) off-label, including those listed below, as part of your treatment for stimulant use disorder if your Workit Health Clinic provider believes it will benefit your treatment.

While not exhaustive, a list of common and notable side effects for off-label drugs that may be prescribed to you include dry mouth, constipation, nausea, headache, decreased appetite or loss of appetite, insomnia, vomiting, decreased appetite, dizziness, dysphoria, abnormal dreams, hypotension, sedation, weakness, fatigue, ataxia, blurred vision, impaired cognition, diarrhea, sexual dysfunction, and somnolence.

Information Related to Treatment for Anxiety and Depression

Overview of Possible Benefits and Risks

Certain medications including selective serotonin inhibitors (SSRIs), norepinephrine serotonin reuptake inhibitors (SNRI), and atypical antidepressants are FDA approved to treat depression and/or anxiety and may relieve the symptoms of depression and/or anxiety.

However, these medications carry general risks and side effects including causing sexual dysfunction (problems with orgasm, ejaculation, and/or erectile dysfunction), and also potentially life-threatening side effects, the risk of suicidal thoughts and behavior, and a severe allergic reaction that can lead to disability and even death. Other potential risks with taking these medications include:

• Antidepressant Discontinuation Syndrome (ADS) may occur if you abruptly discontinue antidepressant medications and may include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal;
• Serotonin Syndrome, while rare, but potentially life-threatening, may occur by using serotonergic drugs and overactivation of the serotonin receptors; common side effects are headache and dizziness;
• Treatment Resistant Depression may occur if treatment fails to produce a response or remission for an individual after two or more treatment attempts of adequate dose and duration;
• All antidepressant medications carry a black box warning about suicidal thoughts and behaviors in children, adolescents, and young adults up to age 24.

Abruptly stopping any of these treatments may cause symptoms including but not limited to anxiety, irritability, agitation, dizziness, nausea and sensory disturbances such as the feeling of having an electric shock. There are alternatives to the prescription-only medicines available from Workit Health Clinic providers like cognitive behavioral therapy (CBT) and stress management techniques for treatment of depression or anxiety.

Benzodiazepines

In certain cases, your Workit Health Clinic provider may prescribe benzodiazepines, which are class IV controlled substances that may help to treat your anxiety and/or depression. Because it is a controlled substance, its use may result in side effects and tolerance, physical dependence, withdrawal, and addiction. For more information regarding these side effects and risks, please review the above section entitled “Controlled Substances”.

Pregnancy and Benzodiazepines

Taking benzodiazepines during pregnancy carries the risk of miscarriage can cause birth defects, and may also lead to the development of dependence and withdrawal symptoms in the fetus.

Immediate Help

If you are a threat to yourself or to other people, you should not use the Workit Health Clinic and should instead call 911 or call the National Suicide Prevention Hotline at 988.

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Based on all of the information provided in this Consent, which you acknowledge that you have read carefully and in full (including clicking and reviewing any other documents and agreements incorporated in this Consent), you hereby confirm your understanding of, and agreement to, all of the following:

Telehealth Acceptance and Agreement

1. You are voluntarily agreeing to use the telehealth services and to receive health care/medical care services and treatment provided to you by your Workit Health Clinic provider primarily through the use of telehealth;
2. You have received or previously received the credentials (license type and number) of your Workit Health Clinic provider;
3. Video, audio, and other photo recordings related to or arising from the telehealth services may be taken and a non-medical individual working with or on behalf of your Workit Health Clinic may be present during the telehealth engagement or have access to your telehealth communications;
4. The delivery of health care/medical care services via telehealth is an evolving field and the use of telehealth in your health care/medical care and treatment from your Workit Health Clinic provider may include uses of technology different from those described in this Consent or not specifically described in this Consent;
5. Even if you expect anticipated benefits, no potential benefits from the use of telehealth or specific results can be guaranteed and in some cases, your condition may not be cured and may get worse;
6. There are risks and limitations in the provision of health care/medical care and treatment via telehealth, including those set forth in this Consent, and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment;
7. Your Workit Health Clinic provider has discussed the use of telehealth with you, including the benefits and risks of telehealth, and you have provided oral consent to your Workit Health Clinic provider for the use of telehealth;
8. Your use of telehealth involves electronic communication of your medical information to your Workit Health Clinic providers who may be located in other areas, including outside of the state in which you reside, and subject to applicable state and federal law and any proper authorizations provided by you or on your behalf, details of your medical history may be disclosed to other medical practitioners and providers including your primary care physician;
9. Each of your Workit Health Clinic providers may determine in his or her sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth and that you may need to seek medical care/health care and treatment from a specialist or other health care provider or via in-person medical care;
10. The privacy and security of your medical information is covered by federal and state law and is subject to any “Release of Information Form” or “HIPAA Authorization Form” that you have completed and to Workit Health’s Privacy Policy and the Workit Health Clinic Notice of Privacy Practices, all of which are incorporated by reference herein, and, subject to applicable law, your telehealth engagement will become part of your medical record;
11. We have implemented technical, physical, and administrative safeguards to protect against unauthorized use or disclosure of your information; however, you acknowledge that your information may still be lost or impermissibly accessed due to technical failures;
12. You are releasing and holding harmless the Workit Health Clinic, its providers, employees, contractors, agents, directors, members, managers, shareholders, officers, representatives, assigns, and successors from any loss of data or information due to technical failures associated with the telehealth service;
13. You were informed on how to contact your Workit Health Clinic provider via alternative methods if your telehealth encounter is disrupted;
14. You may elect to seek services from a provider with in-person clinics as an alternative to receiving telehealth services; and
15. 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.

State-Specific Requirements

If you are receiving telehealth services in one of the following states, your state’s requirements will also apply:

Arizona – for all Arizona patients – All medical reports resulting from a telehealth consultation are part of your medical record as defined in A.R.S. § 12-2291. Dissemination of any images or information identifiable to you for research or educational purposes shall not occur without your consent, unless authorized by state or federal law.

Colorado – for Colorado Medicaid beneficiaries – You may refuse telemedicine services at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

Georgia – for Georgia Medicaid beneficiaries – Dissemination of any identifiable images or information for a telehealth interaction to researchers or other entities shall not occur without your consent. You may withhold or withdraw consent to the telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. Any dispute arriving from the telehealth consult will be resolved in Georgia, and that Georgia law shall apply to all disputes. For all Georgia patients – You acknowledge receiving clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment.

Indiana – for all Indiana patients – You have been informed that if you want to register a formal complaint about a provider, you should visit the following: https://www.in.gov/attorneygeneral/consumer-protection-division/.

Kentucky – for all Kentucky patients – You have been informed that if you want to register a formal complaint about a provider, you should visit the following: https://kbml.ky.gov/grievances/Pages/default.aspx

New Jersey – for all New Jersey patients – You acknowledge that the telehealth encounter may be with a health care provider who is not a physician. You may specifically request that the telehealth encounter be scheduled with a physician and if you request that the telehealth encounter be with a physician, the encounter shall be scheduled with a physician. You have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers.

New York – for New York Medicaid patients – You have the right to select another provider and by selecting another provider, it could delay your receipt of services and may result in the potential need to travel for a face-to-face visit.

North Carolina – for North Carolina Medicaid patients – Providers are expected to send documentation of any telehealth services rendered to a beneficiary’s identified primary care provider or medical home within 48 hours of the encounter for medical services (including behavioral health medication management), obtaining required consent when necessary (as per 42 CFR Part 2 for relevant substance use disorder related disclosures). Documentation can be sent by any HIPAA-compliant secure means.

Ohio – for all Ohio patients – You have provided the street address and city where you are receiving services and have updated the address whenever your site changes.

Tennessee – for Tennessee Medicaid patients – You acknowledge that you have been informed of, received, and reviewed our Privacy Policy. You may refuse telemedicine services at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

Texas – for Texas Medicaid patients – If you have a primary care physician and you consent, your medical records will be notified of your telehealth encounter and may receive your medical information. You acknowledge that you have been informed of, received, and reviewed Workit Health’s Privacy Policy.
You have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at https://www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en https://www.tmb.state.tx.us

Utah – for all Utah patients – You acknowledge that Workit Health disclosed to you (1) any additional fees for telehealth services, if any, and how payment is to be made for those additional fees if they are charged separately; (2) to whom patient health information may be disclosed and for what purpose, including clear reference to any patient consent governing release of patient-identifiable information to a third party; and (3) information regarding the website owner-operator, location, and contact information.

Emergencies

You should never use the Workit Health Clinic in a medical or psychiatric emergency. If you have an emergency, you should call 911 or go to an emergency room.

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By signing this Consent, you represent that (1) you have read this Consent carefully and in full; (2) you understand the risks and benefits of using telehealth in the medical care and health care and in the possible treatment and medications provided to you by your Workit Health Clinic providers; (3) even with these risks, you are voluntarily consenting to receive medical care, health care and possibly receiving treatment and medications; (4) you have the legal capacity and authority and mental competency to provide this Consent for yourself; and (5) you acknowledge, understand, and agree that this Consent is subject to our Terms of Service, Privacy Policy, Notice of Privacy Practice, and the Treatment Agreement each of which is incorporated by reference herein and that address, without limitation, indemnification, intellectual property, dispute resolution, limitation of liabilities, waiver of consequential, special, and other damages, among other terms and conditions.

If you are a parent, guardian, conservator, or custodian signing on behalf of another individual who is unable to consent for him or herself, such as a minor, you represent that you are legally able and entitled to consent on behalf of such individual and agree to all of the above regarding such individual’s receipt of medical care and health care and in the possible treatment and medications provided to such individual by a Workit Health Clinic provider.