IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

IF YOU ARE CONTEMPLATING SUICIDE, CONTACT 9-1-1 OR THE NATIONAL SUICIDE PREVENTION LINE AT 9-8-8.

You are receiving and acknowledging this Telehealth Consent because you are seeking certain health care services from physicians or other health care providers (“Providers”) utilizing telehealth technologies facilitated by the Caire Women’s Health, Inc. (“Upliv”) website and any other related telehealth technologies and/or software (collectively, the “Upliv Platform”). This Telehealth Consent does not modify or supersede any Terms and Conditions, Privacy Notice, or Notice of Privacy Practices of Upliv or the Providers, rather it supplements these terms and documents, and any capitalized terms utilized in this Telehealth Consent but not otherwise defined herein shall have the meaning set forth for such term in the Terms and Conditions, Privacy Notice, or Notice of Privacy Practices. Providers and Upliv require that you read and fully understand this consent before you receive treatment via telehealth.

By creating an account, starting a consult, clicking “I consent to telehealth,” checking a related box to signify your acceptance, or using any other acceptance protocol presented through the Upliv Platform, you indicate that you have reviewed the risks as described herein of receiving services utilizing telehealth technologies and consent to receiving the services. A record of this Telehealth Consent is maintained in the files and records of the applicable Provider delivering your services, and your on-going participation in services provided by Upliv or its affiliated physician practices using telehealth technologies serves as an on-going acknowledgement of your acceptance of this Telehealth Consent and updates at such time as the representations you provide herein.

What is Telehealth?

Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered health care professional at one location and a patient in another location. Telehealth may be used for diagnosis, treatment, follow-up, and/or patient education. Telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters, and interactive audio with store and forward. This “Telehealth Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of utilizing telehealth to meet your health and wellness needs.

What are the Possible Benefits of Telehealth?

It can be easier and more efficient for you to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment.

What are the Possible Risks of Telehealth?

Information transmitted to your Provider may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. Limitations inherent in the use of the Upliv Platform may affect your Provider’s ability to provide health care services to you, and in some cases, an in-person physical examination, test, or other procedure not available on the Upliv Platform might provide information important or relevant with respect to your health care services. In some cases, the quality of the information you submit to your Provider (including any photograph(s) and other data you upload) may affect the quality of the health care services that your Provider is able to deliver through the Upliv Platform.

The technology necessary to interact with your Provider may fail and delay your services. If a technological failure prevents you from communicating with your Provider, you should call the following number: Phone: +1 (619)-377-1244, Monday-Friday, 9:00 a.m. to 5:00 p.m. ET. Although the electronic communication systems that we use will incorporate security protocols to protect your privacy, security protocols could fail, causing a breach of privacy of personal medical information.

As all data exchanged is in a digital format, a data breach enables increased access to your health data.
In rare events, a lack of access to complete medical records and/or the quality of transmitted data could result in adverse drug interactions, allergic reactions, and/or other clinical judgment errors. You may stop or decline any on-going health care services provided by a Provider using the Upliv Platform at any time, although you acknowledge that Upliv has no obligation for your on-going care or selection of separate health care services in such circumstances.

Patient Acknowledgments:

By accepting this Telehealth Consent, you acknowledge you understand and consent to the following:

1. I have reviewed this Telehealth Consent carefully, and understand there are risks, limitations, and benefits of utilizing telehealth.
2. I understand and acknowledge that I must be located in a state in which my Provider is licensed and qualified to provide the telehealth services.
3. I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my health information.
4. In some cases, my Provider may be a nurse practitioner or physician assistant and not a physician.
5. I understand that persons may be present during the telehealth visit other than my Provider in order to operate the Upliv Platform and/or for language translation assistance, if requested. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
6. I understand that information I provide as part of any telehealth offering is viewed as accurate, true, and complete. I understand that I can log into my patient account on the Upliv Platform by logging into Upliv Platform at any time to (i) access or amend any information I may provide, or (ii) review my health information.
7. I understand that there is no guarantee that I will be given a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider. I understand that while the use of telehealth may provide benefits to me, no such benefits or specific results can be guaranteed and my condition may not improve.
8. I understand that there is a risk of technical failures during the telehealth encounter beyond the control of Upliv and my Provider(s). I AGREE TO HOLD HARMLESS UPLIV, ITS AFFILIATED PHYSICIAN PRACTICES, AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
9. I understand that the Upliv Platform makes available a specific set of services and I may need to seek other resources for my other health needs. There is no guarantee that I will be treated by a Provider. My Provider reserves the right to deny care for any reason if, in the professional judgment of my Provider, the provision of the services, including when provided via telehealth, is not medically or ethically appropriate. I understand that the Providers, and not Upliv, are responsible for the quality and appropriateness of the care they render to me and make all decisions regarding clinical care in their independent discretion without the influence of Upliv.
10. I understand that by using the Upliv Platform I am not always speaking or messaging with my Provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Upliv Platform for messages because this is the way that my Provider will communicate important information to me. I understand that if I do not check the Upliv Platform regularly, then my services may be delayed.
11. I understand that I have the opportunity to discuss the use of telehealth, including the health care services, with my Provider(s), including the benefits and risks of such use and the alternatives to the use of telehealth. I have the right to withdraw my consent to the use of telehealth in the course of my care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled, but I understand that the Providers who provide health care services via the Upliv Platform do not offer in-person treatment.
12. I understand that while the Upliv Platform may make available access to pharmacy or diagnostic lab services that are coordinated with the health care services, I am able to request any pharmacy or lab of my preference.  I also understand that my medical information may be shared with contractors and/or affiliates of Upliv for scheduling and billing purposes.
13. I give consent to my Provider to record a telehealth session. I will not record the session without my Provider’s consent.

State-Specific Disclosures: Additional state-specific disclosures will be added as Upliv expands operations.  Such additional disclosures will apply to users accessing the Upliv Platform for the purposes of participating in a telehealth visit as required by state law.