CONSENT AND AUTHORIZATION TO RECEIVE MEDICAL SERVICES THROUGH TELEMEDICINE FROM A PHYSICIAN, NURSE PRACTITIONER, OR REGISTERED NURSE AFFILIATED WITH PEPPY HEALTH CORPORATION

1. Purpose of this Consent and Authorization. The purpose of this form is to obtain your consent to participate in and/or receive medical or nursing care, including a consultation, evaluation, diagnosis, and/or treatment, via telemedicine rather than in-person. In some states, the medical services provided through the Peppy Health Corporation (“Peppy”) application (“the App”) or some of them, may be considered “telehealth” or “telemedicine” under applicable laws. Some of these laws may require your written informed consent to receive medical services from a Peppy affiliated physician, nurse practitioner, or registered nurse (“your Providers”) through the App, via synchronous interactions, asynchronous, store-and-forward electronic communications such as chat, text and photographs (“Technologies”). To ensure compliance with any such laws, and where inapplicable, that you are fully informed, Providers and Peppy require that you submit this consent before your Providers will provide medical and/or nursing services to you through the App. 
2. Provider of Telemedicine Services. Your Providers are your provider of telemedicine services and will be a physician, nurse practitioner, and/or registered nurse, licensed in the state where you are located, who specializes in women’s health and whose professional corporation or medical group is affiliated with Peppy. Your Providers will provide medical and nursing services through the App as your Providers determine are appropriate and meet the applicable standard of care. While your Provider is affiliated with Peppy, your Provider is not employed, owned, or controlled by Peppy. 
3. Nature of the Telemedicine Encounter. 
   
   a. By registering and creating an account with Peppy, you are asking that your Providers provide professional services to you, including the evaluation and potential treatment of your condition, through asynchronous, store-and-forward electronic communications such as text, chat and photographs, and possibly also through a live, synchronous encounter (“Technologies”). 
   
   b. The encounter will be only between you and your Providers, electronically supported by Peppy.  However, Peppy will collect and store the information exchanged between you and your Providers, as an administrative service, as described in the Notice of Privacy Practices (“NPP”) and  Privacy Policy.
   
   c. The encounter will generally include your description of the condition to your Providers through asynchronous chats, and your Providers’ responses, including requests for additional information or recommendations for treatment. Your Providers may also set up live, synchronous encounters.
   
   d. Providers’ responses will not be immediate, but should reach you within 48 hours.  
   
   e. Your Provider may ask you, through the Technologies, to share details of your medical history, symptoms, current medications, better quality photographs, and other health information.
   
   f. Your Provider will review the information you provide and may discuss it with other health professionals, in accordance with the NPP.
   
   g. If your Provider concludes that you have a condition that may be appropriately and effectively treated through telemedicine, your Provider may make treatment recommendations and may prescribe medication. If your Provider determines that appropriate evaluation and treatment cannot be provided using Technologies, you may be advised to seek in-person care from a qualified health care provider.    
4. Risks, Benefits and Alternatives. The benefits of telemedicine include convenient and improved access to care without having to leave your home or travel outside of your local health care community. However, limitations inherent in the use of Technologies may affect your Provider’s ability to provide professional services to you, and in some cases, an in-person physical examination, test, or other procedure not available through your Provider might provide information important or relevant to your health and treatment. In some cases, the quantity of the information you provide to us (including photographs and other data you upload) may affect the quality of the diagnosis, treatment, and/or advice that your Provider provides. Additionally, failures of equipment or Technologies or scheduling issues may cause delays in evaluation or treatment. Further, while you will be asked to provide pertinent information, including for example your medical history, your Provider will not have access to your medical records and may be unable to identify potential adverse drug interactions, allergic reactions, or other errors.
   
   You understand the risks presented by the above issues, circumstances, and disadvantages and that the alternative to a telemedicine consultation is a face-to-face visit with a provider of your choice, which may in some cases be better for you.
   
5. Medical Information and Records. Your Provider and Peppy follow federal and state laws concerning confidentiality protections, patient access to medical records, and copies of medical records. All messages, images, and other communications between you and us regarding “care, treatment, and services” will be copied, included, and maintained in your digital medical record, which we will not automatically send to your regular healthcare provider. Your identifiable images and health information will not be shared with researchers or other entities without your consent, unless specifically permitted by law, as further described in your Provider’s Notice of Privacy Practices and the Privacy Policy.  
6. Unauthorized Access. While we have safeguards in place to protect our digital medical records, in rare circumstances, security protocols could fail, causing a breach of patient privacy. We are not responsible for loss of protected health information (“PHI”) or other data due to technical failures and other circumstances that are beyond our control, and we are not responsible for unauthorized access of PHI while in transmission to you or for safeguarding information once delivered to you.  
7. Rights. You may withhold or cancel your consent to receiving telemedicine services at any time before and/or during your consultation by terminating your user account or notifying your Provider by sending an email to hello@peppy.health or a written request to Peppy Health Corporation, 1209 Orange St., Wilmington, DE 19801. You understand that when you cancel your consent, it is effective only from the date of cancelation forward, and not retroactively. However, if you cancel your consent to communicating using Technologies, your Provider will not have the ability to communicate with you. Otherwise, your cancellation will not affect your right to future care or treatment.
8. Electronic Prescriptions. Your Provider may prescribe medications electronically as part of your telemedicine consultation, and you consent to our use of e-prescribing. The e-prescription service is included in the list of persons with whom we may share information about you. Your Provider may request, consider, and use your prescription medication history as available electronically from other health care providers and/or third party pharmacy benefit payors for treatment purposes, as described in your Provider’s Notice of Privacy Practices.
9. Response Time.  You understand that your communications to us may not be read or answered within a consistent timeframe and if you have an urgent or serious condition requiring immediate attention, CALL 9-1-1, GO TO YOUR NEAREST EMERGENCY OR URGENT CARE CENTER, AND/OR CONTACT YOUR PERSONAL PHYSICIAN, AS APPROPRIATE. 
10. Communications. In general, your Provider will communicate with you only through the App, via secure asynchronous transmission. Communications with you via e-mail, text message, and/or video-chat regarding your care, treatment, and services may be governed by your Provider’s Notice of Privacy Practices.  
11. Consent and Authorization. You acknowledge the following:
    
    a. That you have reviewed and understand the Peppy Terms of Use and Privacy Policy, and your NPP;
    
    b. That you are physically located in the state(s) where your Provider is licensed to practice;
    
    c. That you accept your Provider as your telemedicine provider based on what you consider sufficient information about the identity and credentials of your Provider;
    
    d. That you understand your Provider will not provide medical or nursing services to you in-person or face-to-face;
    
    e. That any diagnosis, treatment recommendations, and/or prescription will be based on your written and/or teleconferencing communications submitted through the App to your Provider, and your Provider’s responsive questions, if any, which you may receive up to 48 hours after your submission;
    
    f. That you have read and understood the above risks, benefits, and alternatives of telemedicine.
    
    g. That these understandings provide you with adequate information to make a decision about whether you wish to consult with and receive telemedicine services from your Provider in accordance with this Consent and Authorization.
    
    h. That you wish to proceed with the telemedicine encounter.