Informed Consent for Telehealth Services

DO NOT USE THE LEVEL IX PLATFORM IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY.

If you are experiencing a medical emergency, immediately:

• Call 911
• Go to the nearest emergency department
• Contact your local emergency medical services
• Call or text 988 if you are experiencing a mental health crisis.

The Level IX platform is not intended to provide emergency medical care.

1. PURPOSE OF THIS INFORMED CONSENT

This Informed Consent for Telehealth Services (“Consent”) explains the nature of telehealth services provided through the Level IX Performance & Longevity platform (“Level IX,” “we,” “our,” or “us”), including the potential benefits, risks, limitations, and your rights as a patient.

Please read this Consent carefully before receiving telehealth services.

2. ABOUT LEVEL IX

Level IX Performance & Longevity is a nationwide telehealth wellness platform that connects eligible patients with independently licensed healthcare providers.

Level IX:

• Is not a hospital, physician practice, pharmacy, or healthcare provider.
• Does not practice medicine.
• Does not employ healthcare providers to make medical decisions on its behalf.
• Does not interfere with the independent medical judgment of healthcare providers.
• Does not diagnose medical conditions.
• Does not prescribe medications.

All healthcare services are provided solely by independently licensed physicians, nurse practitioners, physician assistants, or other qualified healthcare professionals who exercise their own independent professional judgment.

Only your treating healthcare provider determines whether:

• Telehealth is appropriate for you;
• Laboratory testing is necessary;
• Treatment is clinically appropriate;
• A prescription should be issued;
• Follow-up care is required.

3. WHAT IS TELEHEALTH?

Telehealth is the delivery of healthcare services using secure electronic communication technologies rather than traditional face-to-face visits.

Telehealth services may include, when clinically appropriate:

• Medical consultations
• Health assessments
• Review of medical history
• Review of laboratory results
• Medication management
• Wellness counseling
• Treatment recommendations
• Prescription evaluation
• Follow-up care
• Patient education

Telehealth services may occur through:

• Secure video conferencing
• Telephone communications
• Secure messaging
• Electronic medical questionnaires
• Patient portals
• Other secure digital technologies

4. BENEFITS OF TELEHEALTH

Potential benefits include:

• Improved access to licensed healthcare providers
• Convenient care from your home or another private location
• Reduced travel time
• Increased continuity of care
• Faster access to medical evaluation
• Improved access for patients in underserved areas

No specific outcome or medical result can be guaranteed.

5. RISKS OF TELEHEALTH

Potential risks associated with telehealth include:

• Technical interruptions or equipment failures
• Poor internet or communication quality
• Delays in diagnosis or treatment
• Incomplete or inaccurate transmission of medical information
• Security breaches despite reasonable safeguards
• Limitations resulting from the inability to perform an in-person physical examination

If your provider determines that telehealth is not clinically appropriate for your medical needs, you may be instructed to seek in-person medical care or emergency treatment.

6. LIMITATIONS OF TELEHEALTH

Telehealth cannot replace every type of medical care.

Certain medical conditions require:

• Physical examinations
• Diagnostic imaging
• Emergency evaluation
• Surgical care
• Hospital treatment
• In-person laboratory services

Your provider will determine whether telehealth is clinically appropriate for your condition.

7. PROVIDER LICENSURE

Healthcare services are only provided by healthcare professionals who are licensed or otherwise legally authorized to practice in the state where you are physically located at the time services are rendered.

You agree to accurately disclose your physical location before each telehealth encounter.

If your provider is not authorized to provide care in your location, services may not be provided.

8. PATIENT LOCATION

Telehealth services may only be provided when your treating healthcare provider is licensed or otherwise legally authorized to provide care in the state where you are physically located at the time of your telehealth encounter.

Before each telehealth visit, you agree to accurately disclose your current physical location. You understand that providing inaccurate or misleading information regarding your location may prevent your provider from rendering care and may delay or interrupt your treatment.

If your location changes during a telehealth encounter, you agree to immediately notify your healthcare provider.

9. YOUR RESPONSIBILITIES

You agree to:

• Provide complete, truthful, and accurate medical information.
• Disclose all medications, supplements, allergies, and medical conditions.
• Update your health information as changes occur.
• Follow your provider’s treatment recommendations.
• Notify your provider if your symptoms worsen or your condition changes.

Failure to provide accurate information may affect your diagnosis, treatment plan, or eligibility for care.

10. PRESCRIPTIONS

If clinically appropriate, your healthcare provider may prescribe medications.

You understand and acknowledge that:

• No prescription is guaranteed.
• No specific medication is guaranteed.
• Your provider may determine that medication is not clinically appropriate.
• Certain medications cannot legally be prescribed through telehealth.
• Compounded medications may only be prescribed where permitted by applicable law.

All prescribing decisions are made solely by your treating healthcare provider.

11. LABORATORY TESTING

Your provider may require laboratory testing before initiating or continuing treatment.

Laboratory services are performed by independent CLIA-certified laboratories where applicable.

Laboratory testing may occasionally produce:

• False-positive results
• False-negative results
• Inconclusive results
• Delayed results

Your provider will determine how laboratory findings affect your treatment plan.

12. PRIVACY AND CONFIDENTIALITY

Telehealth communications utilize secure technologies designed to protect your Protected Health Information (PHI).

While commercially reasonable administrative, technical, and physical safeguards are maintained, no electronic communication system can be guaranteed to be completely secure.

Your health information will be collected, maintained, used, and disclosed in accordance with applicable federal and state privacy laws, including the Health Insurance Portability and Accountability Act (“HIPAA”), where applicable.

Additional information regarding our privacy practices is available in the Level IX Privacy Policy.

13. ELECTRONIC COMMUNICATIONS

As part of your care, you consent to receive communications from Level IX and your treating healthcare provider through electronic means, including:

• Email
• Secure patient portal messages
• SMS or text messages
• Telephone calls
• Appointment reminders
• Prescription notifications
• Laboratory notifications
• Follow-up communications
• Administrative communications
• Billing communications

You understand that standard messaging and data rates may apply.

While Level IX utilizes reasonable safeguards to protect your information, electronic communications may involve risks, including delayed delivery, technical failures, or unauthorized access beyond our reasonable control.

You may opt out of non-essential communications at any time, although doing so may limit our ability to provide certain services or communicate important information regarding your care.

14. FOLLOW-UP CARE

Your provider may recommend:

• Additional telehealth visits
• In-person evaluation
• Laboratory testing
• Specialist referrals
• Primary care follow-up
• Emergency medical treatment

You agree to follow your provider’s medical recommendations.

15. COORDINATION OF CARE

With your authorization, or as otherwise permitted or required by applicable law, your treating healthcare provider may communicate or coordinate your care with your primary care provider, specialists, laboratories, pharmacies, or other healthcare providers involved in your treatment.

Such coordination may include sharing relevant medical information necessary for continuity of care, medication management, laboratory testing, referrals, and follow-up treatment.

If you do not currently have a primary care provider, your treating healthcare provider may recommend that you establish an ongoing relationship with one when clinically appropriate.

16. MEDICAL RECORDS AND CONTINUITY OF CARE

Your treating healthcare provider will create and maintain medical records relating to the healthcare services provided through the Level IX platform in accordance with applicable federal and state laws.

You may request access to your medical records as permitted by applicable law.

Upon your written authorization, or as otherwise permitted or required by law, copies of your medical records may be shared with your designated healthcare providers to promote continuity of care.

Telehealth services are intended to complement—not replace—your relationship with your primary care provider. You are encouraged to maintain routine preventive and ongoing healthcare with your local healthcare providers.

17. RIGHT TO WITHDRAW CONSENT

You may withdraw your consent to receive telehealth services at any time.

Withdrawal of consent will not affect healthcare services previously provided but may limit your ability to receive future telehealth services through the Level IX platform.

18. NO GUARANTEE OF RESULTS

Healthcare outcomes differ among individuals.

Neither Level IX nor your healthcare provider guarantees:

• Treatment eligibility
• Prescription approval
• Medication availability
• Specific medical outcomes
• Weight loss
• Hormone optimization
• Performance enhancement
• Longevity improvements
• Any particular clinical result

19. FINANCIAL RESPONSIBILITY

Level IX currently operates as a cash-pay telehealth wellness platform.

Patients are responsible for payment of all applicable fees.

Payment does not guarantee:

• Treatment
• Laboratory testing
• Medication
• Prescriptions
• Continued care

20. ACKNOWLEDGMENT OF PROVIDER INDEPENDENCE

You understand and acknowledge that:

• Your treating healthcare provider independently exercises professional medical judgment.
• Level IX does not direct, supervise, or influence clinical decisions.
• Level IX cannot require a provider to diagnose, prescribe, or treat any patient.
• Your provider may determine that you are not an appropriate candidate for treatment or may discontinue treatment when clinically appropriate.

21. INFORMED CONSENT

By accepting this Consent, you acknowledge that:

• You have carefully read this entire document.
• You understand the nature of telehealth services.
• You understand the potential benefits, risks, and limitations of telehealth.
• You have had the opportunity to ask questions.
• Your questions have been answered to your satisfaction.
• You understand that telehealth may not be appropriate for every medical condition.
• You understand that no diagnosis, treatment, prescription, or medical outcome is guaranteed.
• You understand that all medical decisions are made solely by your independently licensed healthcare provider.
• You voluntarily consent to receive healthcare services through telehealth when clinically appropriate.

22. STATE-SPECIFIC TELEHEALTH DISCLOSURES

Certain states require additional disclosures or acknowledgments regarding telehealth services. By accepting this Consent, you acknowledge and agree to the following, as applicable based upon the state in which you are physically located at the time services are provided:

California: You understand that you have the right to withhold or withdraw your consent to telehealth at any time without affecting your future right to receive medical care or treatment. If telehealth is not clinically appropriate for your condition, your provider may recommend an in-person evaluation.

Florida: If you participate in a physician-supervised weight management program or receive weight management medications, you acknowledge that you have been advised regarding the importance of gradual weight loss, appropriate medical monitoring, nutrition, physical activity, and ongoing follow-up care. Provider qualifications are available upon request.

Texas: Where required by applicable law and with your authorization, your treating healthcare provider may provide appropriate medical information regarding your telehealth treatment to your designated primary care provider to support continuity of care.

Other States: Additional disclosures required by the laws of the state in which you receive telehealth services are incorporated into this Consent by reference and shall apply to the extent required by applicable law. If any provision of this Consent conflicts with applicable state law, the applicable state law shall control.

23. ELECTRONIC CONSENT

By selecting the “I Agree” checkbox, clicking “Accept”, creating an account, submitting a medical intake questionnaire, scheduling a consultation, completing a purchase, or otherwise electronically indicating your acceptance, you acknowledge and agree that:

• You have read this Informed Consent for Telehealth Services in its entirety.
• You fully understand the information contained in this Consent.
• You have had the opportunity to ask questions before receiving telehealth services.
• You voluntarily consent to receive healthcare services through telehealth technologies when clinically appropriate as determined by your treating healthcare provider.
• You understand that you may withdraw your consent at any time, subject to applicable law.
• You acknowledge that your electronic acceptance constitutes your legal signature and has the same legal force and effect as a handwritten signature under the Electronic Signatures in Global and National Commerce Act (“E-SIGN Act”), the Uniform Electronic Transactions Act (“UETA”), and other applicable federal and state laws.
• You authorize Level IX Performance & Longevity and your treating healthcare provider to rely upon your electronic acceptance of this Consent as valid evidence of your informed consent to receive telehealth services.
• You acknowledge and agree that this Consent will remain in effect for future telehealth encounters conducted through the Level IX platform unless and until you revoke your consent in writing, your treating healthcare provider determines that a new consent is required, or applicable law requires a new consent to be obtained.

By electronically accepting this Consent, you certify that you have read, understood, and voluntarily agree to all of the terms and conditions set forth in this Informed Consent for Telehealth Services.