I agree to receive this health care service provided by health care practitioners whom I selected. As a telehealth service, I unnderstand that the health care preactitioners, providing the identified services to me and utilising the Trichology telehealth platform through the website as defined in our terms of use IS(are) located in locations remove from my location.

The scope of care will be at the sole discretion of the health care practitioner(s) from whom I am receiving this service, with no guarantee of diagnosis, treatment or prescription. The health care practitioner(s) will determine whether or not the condition is being diagnosed and/or treated is appropriate for a telehealth encounter via the website.

I also agree and authorise my health care practitioner(s) to release information regarding my the telehealth visit to Trichology consistent with the terms of use set forth on site.

A telehealth service means that my health care services are provided, as applicable by practitioners at a distant location using interactive video and/or audio conferencing in real time or (B) with the aid of exchanged digital images of my condition by an asynchronous remote evaluation and consultation.

I also understand:

• I may have to travel to see a health care practitioner in-person for certain diagnosis and treatment matters.
• The same confidentiality and privacy protections that apply to my other health care services also apply to these telehealth services.
• I may have to travel to see a health care practitioner in-person for certain diagnosis and treatment matters.
• I have access to all of my health and wellness information pertaining to the telehealth services in accordance with applicable laws and regulations.
• I may need to see an appropriately trained health care professional in-person immediately after the telehealth service if an urgent need arises.
• My health care information may be shared with other individuals for treatment, payment and health care operations purposes.

I have read this document carefully and all my questions were answered to my satisfaction. I hereby consent to participate in the telehealth visit with my selected health care practitioner(s) using the site pursuant to the terms, conditions, standards and requirements referenced at the website.