Informed Consent to Telehealth Services

Thank you for choosing Soma Health LLC! You are viewing this form because you have elected to receive telehealth services through the Soma Health platform. Medical services are provided by independent, licensed healthcare providers affiliated with SamaritanMD; Soma Health does not provide medical services. Your practitioner is a licensed provider.

By clicking “I Agree,” I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF TELEHEALTH, AND BY ACCEPTING THESE TERMS OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN TELEHEALTH UNDER THESE TERMS.

What is Telemedicine?

Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. Soma Health allows you to receive treatment from a healthcare practitioner without having to travel to another location or schedule a separate appointment and helps you avoid long wait times that you might otherwise experience at an in-person visit.

How is Care Delivered?

Care may be delivered via secure online intake, messaging, or video, as determined by your licensed provider. Your provider decides which method is appropriate for your care and may request a video visit or additional information at any time.

Soma Health’s platform (“Platform”) supports the following telehealth services: 1) secure information collection through online patient intake questionnaires; 2) secure messaging, including text-based provider-patient interactions through short message service (“SMS”) and multimedia messaging service (“MMS”) communications; and 3) video visits, when your provider determines one is appropriate.

What are the Possible Risks to Using Telehealth?

As with any medical treatment, there are potential risks associated with the use of telehealth. Soma Health believes that the likelihood of these risks materializing is very low.

These risks may include, without limitation, the following:

• Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur.

• Security protocols could fail, causing a breach of privacy of personal medical information.

• Because Soma Health does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur.

• Telehealth services are NOT emergency services and your Personal Data (as defined in the Soma Health Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR THE CARE PROVIDED THROUGH A TELEHEALTH ENCOUNTER VIA THE PLATFORM.

A licensed provider reviews each intake and determines whether you are eligible for treatment. A prescription is not guaranteed.

Your Rights and Acknowledgements:

• You have the same privacy rights via telehealth that you would have during an in-person visit. Dissemination of any identifiable images or information from the telehealth visit to researchers or other entities will not occur without your written consent. For more information about how we protect your privacy, please read the Soma Health Privacy Policy at https://joinsoma.health/privacy-policy

• Telehealth may involve electronic communication of your personal medical information to healthcare practitioners who may be located in other areas, including out of state.

• You understand that you may expect the anticipated benefits from the use of telehealth, but that no results can be guaranteed or assured.

• You understand that all information submitted to Soma Health via text message and entered by your healthcare practitioner in the Soma Health Platform will be part of your medical record and available to you by emailing hello@joinsoma.health. This information will have the same restrictions on dissemination without your consent.

• You understand that your healthcare practitioner’s initial text message to you will include his/her name and credentials, and this will be recorded in the Soma Health Platform as part of your medical record.

• You understand you may withdraw your consent and delete your patient profile at any time by emailing hello@joinsoma.health.

• You understand that your healthcare information may be shared with other individuals in accordance with the Soma Health Privacy Policy and regulations or laws in state or territory in which you are located.

• You further understand that your healthcare information may be shared in the following circumstances:

When a valid court order is issued for medical records.

Reporting suspected abuse, neglect, or domestic violence.

Preventing or reducing a serious threat to anyone's health or safety

Call/Email/Text Messaging Consent: You expressly consent to allow Soma Health or your licensed provider to call, email, or text you (via SMS and/or MMS) with or regarding Personal Data (as defined in the Soma Health Privacy Policy), appointments, or similar matters related to your telehealth encounters using the contact information you have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier’s normal rates may apply. This is consent, not a condition of purchase.

You may revoke this consent at any time by emailing us at hello@joinsoma.health.

This Informed Consent to Telehealth Services is valid during your entire treatment through Soma Health.