1. I consent to and authorize evaluation, testing (if possible), and treatment (if possible) by Citron Telecare (“Entity”), a telemedicine practice, and by the Entity’s nurses, employees, physicians, consultants, associates, and assistants, or as directed pursuant to standing medical orders or protocols. I understand that it may be necessary for representatives of outside health care company to assist in my care. I understand that in connection with my treatment, photos, audio recordings, or videos may be taken.

2. I understand that electronic communications such as email, text messages, video, or audio, etc. conferencing technology will be used to provide patient care which is not the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. Data and phone charges may apply from your carrier. We are not responsible for any charges that your communication company charges for the connection.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that virtual connections are not adequate for the situation.

4. I understand that my healthcare information may be shared with other individuals / other entities for purposes such as but not limited to scheduling, billing, analytics, and marketing. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people / entities will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination virtual room: and or (3) terminate the consultation at any time.

5. I understand that I am choosing to participate in telemedicine care on my own accord. I understand that are alternatives to telemedicine care.

6. No guarantee. I acknowledge that no guarantees or warranties have been made to me with the respect to treatment or services provided by the Entity. This agreement may be amended by the Entity anytime. If this agreement is amended, then a copy will be provided to the patient upon request by the patient. If the patient does not agree to the amendments, the patient or the Entity has the right to immediately terminate the relationship between the patient and the Entity.

Acknowledgement:

I, the undersigned, certify that I have read and fully understand the information in this form and agree to be bound by its terms. I fully understand its contents including the risks and benefits of telemedicine.