This electronic material contained within this website and app (herein by, "the platform") is intended to provide you with detailed information about the policies, programs, agreements and consents of HerpAlert. Please read each section thoroughly before making your final decision to move forward with the potential diagnosis and treatment process.

I,, understand that HerpAlert is a telehealth marketing platform that connects patients and physicians. Diagnosis and treatments provided via the HerpAlert website and/or app is authorized and conducted by an outside healthcare professional contracted to utilize HerpAlert professional services.

I,, understand, agree and certify that the consents, agreements and policies contained on the platform shall be considered equivalent to traditional paper copies and I certify that my electronic signatures, electronic initials, auto-filled name and check boxes shall serve the legal equivalent of a physical, signed document. Moreover, I certify that the medical information I provide will be accurate and complete. I also understand and agree that this general consent will remain in effect for any and all treatments I choose, and may be supplemented in the future by written, electronic or verbal information from HerpAlert in the future.

I, , understand that a contracting HerpAlert healthcare professional may utilize a comprehensive team of healthcare professionals to assist, assess, implement and supervise patient diagnosis and treatment. These individuals may include physicians (MDs/DOs), Nurse Practitioners (NPs), Physician Assistants (PAs), Registered Nurses (RNs) and ancillary non-medical, administrative staff. I acknowledge that I may be treated by any of, any combination of, or even all of these allied health care professionals during the course of my potential diagnosis and treatment.

I, , understand and agree that diagnosis and treatment offered by HerpAlert are not covered by public or private insurance plans. I understand that HerpAlert will not submit any claims to any insurance carriers. I understand that payment is due before services are rendered. I fully acknowledge that I am personally responsible for all fees and charges incurred in connection with my purchase, and I completely understand that there is absolutely NO refunding of any patient fees, payments, charges, credit, gift certificates, product purchases, pre-paid packages or services. HerpAlert prides itself on patient satisfaction but I understand and agree that HerpAlert also retains the right to refuse service to anyone.

I, , understand, agree and consent that HerpAlert and their employees, independent contractors, associates, agents and representatives participate in Telehealth (telemedicine), and will require that photographs and/or use video (for "store & forward" or teleconferencing technology) of the area to be diagnosed and treated. These recordings will be available only to our medical staff members. HerpAlert follows HIPAA guidelines regarding patient confidentiality and privacy, therefore recordings are used internally. Only the treated area/area to be assessed will be shown in these photographs and videos.

I, , understand and agree that HerpAlert will contact me. I will allow this communication to come in the form of live telephone calls, automated telephone appointment reminder calls, text messages, e-mails, electronic surveys, App notifications, U.S mail, social media or by any means convenient to HerpAlert. I understand that HerpAlert may also send other communications informing me of changes to office policies, new technology, announcements and specials that I may find invaluable or informative. I understand that I may opt out of any or all communication measures any time by contacting HerpAlert in writing.

I, , understand that I have a right to view a copy of my medical records. In accordance with state regulations, I understand that there may be a "reasonable fee" associated with copying medical records. At HerpAlert this fee typically consists of an administrative charge of $10.00 plus $0.25 for each black & white page, and $1.00 per color page and photograph. This fee may be altered or amended depending on the specific state in which you are located. I understand that this administrative fee must be received prior to the printing and mailing of the records. All documents will be printed and then physically mailed to an address that you provid. I understand that medical records (including photos) will not be transmitted via e-mail or fax.

I, , agree and certify that I have had ample time to read this electronic agreement in its entirety, and that I have thoroughly reviewed each and every section that I have signed and/or initialed electronically. I also certify that I have not taken any medication that might impair my ability to understand this information, and was not rushed or pressured to agree and/or certify to the information contained herein.

I, , understand that many states have laws regarding the exposure and/or transmission of an STD (sexually transmitted disease). I acknowledge that HerpAlert cannot offer information or advice to me in this regard and I agree to seek a legal opinion from an attorney in my state on this matter if necessary. Furthermore, I agree that the disclosure of my sexual health history to past, present, and future partners is my own responsibility. I understand that HSV (herpes simplex virus) cannot be cured and having HSV any necessitate continued treatment over time.

I,, understand and agree that if my suspected herpes lesions persist or worsen, or if any other medical condition or symptom arises, I will promptly follow up with a healthcare provider in-person. I certify that my health care is my sole responsibility and HerpAlert only provides temporary treatment for the symptoms herpes simplex virus.

I, , understand that a cure for herpes or cold sores is not possible. I do understand that the frequency and duration of a herpes or cold sore outbreak can be minimized with prompt treatment via an oral anti-viral medication and that is the reason I am seeking care from HerpAlert.

I, , understand that HerpAlert offers a traditional diagnosis of herpes and cold sores via an electronic review of a patient's history, current symptom(s), and/or electronic clinical pictures. I do understand that alternatives to diagnosis exist and include, but are not limited to, a microscopic evaluation of an active herpes sore or a PCR blood test. As such, by utilizing HerpAlert, I am agreeing to be diagnosed via the traditional method of clinical information evaluation. I understand and agree that if I am interested in diagnosis via another means, I will make arrangements to be evaluated in-person by a healthcare provider in my area.

I, , understand that HerpAlert may provide a prescription anti-viral medication to me. This medication is provided at the sole discretion of the prescribing doctor. While I may request a specific medication, dose, or amount, I fully understand that the healthcare practitioner has no obligation to fulfill my request. Because the treatment of herpes and cold sores is completely voluntary and elective, an alternative option is no treatment at all.

I, , understand that HerpAlert may not provide me with a refill of the anti-viral medication I have been prescribed. I understand that I will have to reuse the HerpAlert platform, pay another fee, and request a new medication when the need arises.

I, , understand that the having one sexually transmitted infection (like herpes or cold sores) statistically increases the likelihood of having a different sexually transmitted infection. I agree that it is my sole responsibility to seek diagnosis and treatment of all other sexually transmitted infections and diseases as well as for the care of my overall health.

I, , understand that any prescription medication can have side effects. I certify that I will discuss all potential side effects with the pharmacy staff when I pick up the medication I am prescribed.

I, , agree to start or maintain a relationship with a primary care provider as HerpAlert only diagnoses and treats the herpes simplex virus.

I, , have been given ample time to read this informed consent and I agree to it completely and fully.

Patient Information

All capitalized terms used in this Informed Consent for Telemedicine Services (“Consent Form”) but not defined herein have the meanings assigned to them in the Terms of Service available on www.HerpAlert.com (“Website”). For avoidance of any doubt, the terms "HerpAlert", "we", "us", or "our" refer to Derma Corporation and HA Telehealth, P.C. doing business as HerpAlert, and the terms “I” "you" and "yours" refer to the client using the Service and Website and App (collectively, the “Platform”).

Purpose

The purpose of this Consent Form is to provide you with information about telemedicine and to obtain your informed consent to participate in a telemedicine health service as part of your medical care.

Telemedicine involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare professional and a client who are not in the same physical location. Telemedicine may be used for diagnosis, treatment, follow-up and/or client education, and may include, but is not limited to:

• Electronic transmission of medical records, photo images, personal health information or other data between a client and a healthcare professional.
• Interactions between a client and healthcare professional via audio, video and/or data communication.
• Use of output data from medical devices, sound and video files.

Benefits of Telemedicine

Use of Telemedicine:

• Permits increased efficiency in evaluations, diagnoses, consultations, and treatment.
• Can be easier and more efficient for you to access medical care and treatment.
• Allows you to interact with medical professionals and obtain medical care and treatment at times that are convenient for you without the necessity of an in-office appointment.

Potential Risks of Telemedicine

As with any medical service, there are potential risks associated with the use of telemedicine. The potential risks associated with the use of telemedicine are rare, but may include the following:

• Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by your medical Provider(s).
• A lack of access to complete medical records or your failure to provide complete and accurate medical information or records may result in adverse drug interactions or allergic reactions or other medical judgment errors.
• Delays in medical evaluation/treatment could occur due to failures of the technology.
• Security protocols or safeguards could fail causing a breach of privacy.
• The inability of your Provider to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you and you may be required to seek alternative care.

Potential Risks of Telemedicine

The Providers at HerpAlert may be providing you with prescription medications. As with any medications, those prescribe to you may result in adverse reactions. Please note that if you are taking any additional medications there may be the potential for drug interactions between your existing medications and the medications prescribed.  By signing this informed consent form you are agreeing to provide an accurate list of all prescription and over the counter medications you are currently taking or have taken within the past month.  While our medical Providers prescribing you these medications will check for potential medications interactions before prescribing medication, our Providers are not liable for any harm or damages caused by an adverse reaction caused by these medications directly or any associated medication interactions.

Packaging and Fulfillment Restrictions

The medication, if approved, may not be shipped in child-resistant packaging and must be kept out of the reach of children. Given regulatory requirements in certain jurisdictions, your professional(s) treatment options, especially pertaining to certain prescriptions may be limited.

INDEMNIFICATION

YOU AGREE TO INDEMNIFY AND HOLD HARMLESS DERMA CORPORATION AND HA TELEHEALTH P.C., ITS EMPLOYEES, AGENTS, DIRECTORS, CLIENTS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE NEGLIGENCE OF DERMA CORPORATION AND HA TELEHEALTH P.C.

Your Privacy Rights

HerpAlert uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Use of the Platform and Services is governed by our Notice of Privacy Practices, copies of which may be found on our Website. If you choose to share your protected health information over email, telephone or video communications, you acknowledge that such email, telephone or video communications may not be encrypted and/or may not be a secure method of communication, and you assume the risk of such unsecured communications. You authorize HerpAlert to use and publish any comments you choose to share about the Service, including comments shared in patient satisfaction surveys, unless otherwise specified. HerpAlert will only publish comments using your first name.

By accepting this Informed Consent for Telemedicine Services, you acknowledge and agree to the following:

• I,, understand that HerpAlert is a telemedicine platform that connects healthcareprofessionals with patients.
• I,, understand that HerpAlert cannot and does not directly offer a clinical a diagnosis nor does HerpAlert provide prescriptions medications. I understand that these services are provided by healthcare professionals who utilize the HerpAlert platform.
• I,, have read this Informed Consent for Telemedicine Services carefully, andunderstand the risks and benefits of the use of telemedicine in the medical care and treatment provided to me by healthcare provider who utilize the HerpAlert platform.
• I,, understand, agree and certify that the consents, agreements and policies contained on the platform shall be considered equivalent to traditional paper copies and I certify that my electronic signatures, electronic initials, auto-filled name and check boxes shall serve the legal equivalent of a physical, signed document. Moreover, I certify that the medical information I provide will be accurate and complete. I also understand and agree that this general consent will remain in effect for any and all treatments I choose, and may be supplemented in the future by written, electronic or verbal information from HerpAlert in the future.
• I,, understand that providers who utilize the HerpAlert platform may consist of a comprehensive team of healthcare professionals that assist, assess, implement and supervise patient diagnosis and treatment. These individuals may include physicians (MDs/DOs), Nurse Practitioners (NPs), Physician Assistants (PAs), Registered Nurses (RNs) and ancillary non-medical, administrative staff. I acknowledge that I may be treated by any of, any combination of, or even all of these allied health care professionals during the course of my potential diagnosis and treatment and that the care is provided by the providers who utilize the HerpAlert platform.
• I,, understand and agree that diagnosis and treatment offered by HerpAlert is not covered by public or private insurance plans. I understand that HerpAlert and the providers who utilize the HerpAlert platform will not submit any claims to any insurance carriers. I understand that payment is due before services are rendered. I fully acknowledge that I am personally responsible for all fees and charges incurred in connection with my purchase, and I completely understand that there is absolutely NO refunding of any patient fees, payments, charges, credit, gift certificates, product purchases, pre-paid packages or services.
• I,, understand and acknowledge that HerpAlert prides itself on patient satisfaction but I understand and agree that HerpAlert also retains the right to refuse service to anyone.
• I,, understand, agree and consent that HerpAlert and their employees, independent contractors, associates, agents and representatives participate in Telehealth (telemedicine), and will require that photographs and/or use video (for "store & forward" or teleconferencing technology) of the area to be diagnosed and treated. These recordings will be available only to our medical staff members. HerpAlert follows HIPAA guidelines regarding patient confidentiality and privacy, therefore recordings are used internally. Only the treated area/area to be assessed will be shown in these photographs and videos.
• I,, understand and agree that HerpAlert will contact me. I will allow this communication to come in the form of live telephone calls, automated telephone appointment reminder calls, text messages, e-mails, electronic surveys, App notifications, U.S mail, social media or by any means convenient to HerpAlert. I understand that HerpAlert may also send other communications informing me of changes to office policies, new technology, announcements and specials that I may find invaluable or informative. I understand that I may opt out of any or all communication measures any time by contacting HerpAlert in writing.
• I,, understand that I have a right to view a copy of my medical records. In accordance with state regulations, I understand that there may be a "reasonable fee" associated with copying medical records. At HerpAlert this fee typically consists of an administrative charge of $10.00 plus $0.25 for each black & white page, and $1.00 per color page and photograph. This fee may be altered or amended depending on the specific state in which you are located. I understand that this administrative fee must be received prior to the printing and mailing of the records. All documents will be printed and then physically mailed to an address that you provided. I understand that medical records (including photos) will not be transmitted via e-mail or fax.
• I,, agree and certify that I have had ample time to read this electronic agreement in its entirety, and that I have thoroughly reviewed each and every section that I have signed and/or initialed electronically. I also certify that I have not taken any medication that might impair my ability to understand this information, and was not rushed or pressured to agree and/or certify to the information contained herein.
• I,, understand that many states have laws regarding the exposure and/or transmission of an STD (sexually transmitted disease). I acknowledge that HerpAlert cannot offer information or advice to me in this regard and I agree to seek a legal opinion from an attorney in my state on this matter if necessary. Furthermore, I agree that the disclosure of my sexual health history to past, present, and future partners is my own responsibility. I understand that HSV (herpes simplex virus) cannot be cured and having HSV any necessitate continued treatment over time.
• I,, understand and agree that if my suspected herpes lesions persist or worsen, or if any other medical condition or symptom arises, I will promptly follow up with a healthcare provider in-person. I certify that my health care is my sole responsibility and HerpAlert only provides temporary treatment for the symptoms of herpes simplex virus.
• I,, understand that a cure for herpes or cold sores is not possible. I do understand that the frequency and duration of a herpes or cold sore outbreak can be minimized with prompt treatment via an oral anti-viral medication and that is the reason I am seeking care from HerpAlert.
• I,, understand that HerpAlert offers a traditional diagnosis of herpes and cold sores via an electronic review of a patient's history, current symptom(s), and/or electronic clinical pictures by a healthcare provider who utilizes the HerpAlert platform. I do understand that alternatives to diagnosis exist and include, but are not limited to, a microscopic evaluation of an active herpes sore or a PCR blood test. As such, by utilizing HerpAlert, I am agreeing to be diagnosed via the traditional method of clinical information evaluation. I understand and agree that if I am interested in diagnosis via another means, I will make arrangements to be evaluated in-person by a healthcare provider in my area.
• I,, understand that I am welcomed and encouraged to forgo the use of HerpAlert and instead seek an in-person evaluation from a healthcare provider, however I have chosen to use HerpAlert so that I may be connected to a licensed healthcare provider via the HerpAlert platform.
• I,, understand medicine is not an exact science and that my clinical diagnosis may differ from an in-person evaluation that I may receive in the future.
• I,, understand that HerpAlert may provide a prescription anti-viral medication to me. This medication is provided at the sole discretion of the prescribing doctor utilizing the HerpAlert platform. While I may request a specific medication, dose, or amount, I fully understand that the healthcare practitioner has no obligation to fulfill my request and that all prescription decisions are made by the healthcare provider utilizing the HerpAlert platform and not by HerpAlert. Because the treatment of herpes and cold sores is completely voluntary and elective, an alternative option is no treatment at all.
• I,, understand that HerpAlert may not provide me with a refill of the anti-viral medication I have been prescribed. I understand that I will have to reuse the HerpAlert platform, pay another fee, and request a new medication when the need arises.
• I,, understand that the having one sexually transmitted infection (like herpes or cold sores) statistically increases the likelihood of having a different sexually transmitted infection. I agree that it is my sole responsibility to seek diagnosis and treatment of all other sexually transmitted infections and diseases as well as for the care of my overall health.
• I,, understand that any prescription medication can have side effects. I certify that I will discuss all potential side effects with the pharmacy staff when I pick up the medication I am prescribed.
• I,, agree to start or maintain a relationship with a primary care provider as HerpAlert only diagnoses and treats the herpes simplex virus.
• I,, have been given ample time to read this informed consent and I agree to it completely and fully
• I,, understand that the delivery of healthcare services via telemedicine is an evolving field and that the use of telemedicine in my medical care and treatment may include uses of technology not specifically described in this consent.
• I,, understand that while the use of telemedicine may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
• I,, understand that Providers utilizing the HerpAlert platform may determine, in his or her sole discretion, that my condition is not suitable for treatment using telemedicine, and that I may need to seek medical care and treatment in-person or from an alternative source.
• I,, understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telemedicine services.
• I,, understand that I have access to all of my health and wellness information pertaining to the telemedicine services in accordance with applicable laws and regulations.
• I,, understand that I can withhold or withdraw this consent at any time by no longer seeking Services through the Platform or by providing notice to HerpAlert of such withdrawal. HerpAlert has the right to refuse access to its Platform or its Services to me at any time, for any reason, or for no reason at all.
• I,, agree and authorize my health care professional to share information regarding the telemedicine exam with other individuals for treatment, payment and health care operations purposes.
• I,, understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telemedicine professional so that my professional can accurately determine what services I need. I further understand that my professional will determine whether telemedicine is appropriate for me at this time, based on the condition being diagnosed and/or treated.
• I,, give my informed consent to the use of telemedicine by healthcare professionals utilizing the HerpAlert platform.
• I,, understand that HerpAlert does not offer refunds for any payment made.

I UNDERSTAND THAT BY CHECKING THE "AGREE" BOX I AM AGREEING TO THE FOREGOING ACKNOWLEDGMENTS AND DISCLOSURES INCLUDING HERPALERT TERMS OF SERVICE AND NOTICE OF PRIVACY POLICIES. FURTHER, FOR PURPOSES OF THIS INFORMED CONSENT, MY ACT OF CHECKING “I Agree” BOX SHALL CONSTITUTE MY ELECTRONIC SIGNATURE AND ON-GOING AGREEMENT TO THESE TERMS OF USE (IN WHATEVER FORM).