Consent to Request Telehealth and In-Person Medical Services

Before you give your consent to request telehealth service, please be aware of how care (the “Services”) is received from Duval Medical, P.A., Quaker Ridge Medical, PLLC, Avalon Medical, PC, & Redwood Medical, PC affiliated with Fountain Vitality, Inc. and each of their affiliates and providers (“Fountain”), of which Service is provided through the the Fountain website or other messaging portal applications (the “Platform”) which is operated and/or supported by Fountain Vitality, Inc. (either directly or through one one of its vendors).

If you have any questions, please send us an electronic message at support@fountain.net

You understand that you should never use the Platform in a medical emergency. You understand that in a medical emergency you should dial 911 or visit an emergency room.

The telehealth services available through the Platform, either directly through us or through one of our vendors, may include (i) providing individuals with information on health care related to the assessment and treatment of individuals’ testosterone levels; (ii) facilitating individual assessments and blood tests; and (iii) an online communication platform as a means of direct access to health care providers provided by Fountain and similar affiliated professional entities for communication, consultations, assessments, and treatment by such health care organizations and their providers of testosterone deficiencies and other closely related deficiencies.

In using the Platform, you understand that you will be provided with the name, credentials, licensure/certification, and qualifications of the medical professional who will be providing your care. You further understand that certain Services may be provided through the Platform by non-physician practitioners such as Nurse Practitioners or Physician Assistants.

You understand that by using the Platform, you may not have an in-person physical exam that might identify a potentially serious medical condition. You further understand that you have the option of seeking the same care in-person with the provider of your choice. You also understand and agree that your blood work and the health information you provide through the Platform may be the only source of health information used by the medical professionals during the course of your evaluation and treatment through the Platform, and that such professionals may not have access to medical records or information held with your primary provider. You certify that all of the information you provide Fountain must be true, accurate, and complete. You understand that if you knowingly provide false, misleading, or incomplete information to a medical professional, you may not be able to receive Services through the Platform.

You agree that it is your choice whether or not to use the Platform and the Services it offers. You understand that at any time, you can change your mind about receiving Services through the Platform. You may obtain copies of your medical records for Services received through the Platform by sending us a message through the Platform.

Through this Platform and the Services it offers, you understand that you will be given information about the test(s), treatments(s), and procedures(s) to be provided, including the benefits, risks, possible problems or complications, and alternate choices. You understand that you are not guaranteed treatment through the Platform and that it may be determined, that through information you provide that you are not appropriate for treatment through the Platform.

You understand that you will need to pay for certain Services received through the Platform yourself and that any insurance you have may not reimburse you for it. You understand that by using this Platform, you are freely electing to pay out of pocket for all Services and prescriptions provided through the Platform and that you may be foregoing discounts or insurance coverage that might otherwise be available to you if you sought care in another health care setting. You understand that it is your responsibility to arrange and pay for any follow-up care that Fountain recommends you receive. You understand that you will be told how to get care in the case of an emergency. You understand that by using the Platform, you may receive medications more slowly than if you received care in a different setting.

You understand that if you are using the Platform, you are responsible for having the latest version of the Platform on your mobile telephone or device and for having sufficient network or wireless connection to be able to use the Platform.

You understand that you should ask questions about anything you do not understand by sending an electronic message through the Platform. You understand that a medical professional is available to answer any questions you may have. Fountain aims to respond to any message sent through the Platform within one business day, and to respond to any telephone messages within one business day. However, Fountain may be delayed in responding to any message, and does not guarantee a response within one business day. Business days are Monday through Friday. You understand that you must check the Platform for messages because this is the way that Fountain will communicate with you. You understand that if you do not check the Platform regularly, your care and any drug treatment may be delayed. You understand that you may receive email communications through the Platform.

You further understand that the electronic nature of the Services means that there is a greater risk to the privacy of your electronic health information. By agreeing to use the Platform, you are consenting to Fountain’s sharing of your protected health information with certain third parties as more fully described in our Privacy Policy. In addition to the information you share with us through the Platform, the Platform may also collect your device identifier and your geolocation. This information may be necessary to be able to assign you to a medical professional licensed in your state. You understand, agree, and expressly consent to Fountain obtaining, using, storing, and disseminating to necessary third parties, information about you and your image, as necessary to provide Services through the Platform. You further understand that records of Services provided to you through the Platform may be lost through technical failures. You understand that if you are experiencing technical difficulties through the Platform, you may send a message through the Platform. You hereby release and hold harmless Fountain from any loss of data or information due to technical failures associated with the Platform.

If you would like to have the records relating to the telehealth services received through the Platform sent to your primary care provider, you understand that you will need to send an electronic message through the Platform requesting such transfer of records.

By agreeing to receive the Services through the Platform, you acknowledge that treatment is associated with a number of risks including, but not limited to, the following:

TESTOSTERONE TREATMENT

Special precautions before using topical testosterone

Tell your doctor if you have a known or suspected allergy to testosterone or other medications. Tell your doctor about all your prescription and non-prescription medications (including supplements) that you take or are planning to take. In particular, it’s important to mention if you take any anticoagulants (blood thinners), oral steroids, prednisone, or insulin. Tell your doctor if you have a history of breast or prostate cancer. Tell your doctor if you have a history of benign prostatic hyperplasia (BPH), diabetes, high blood calcium levels, sleep apnea, or heart, liver, kidney or lung disease. Tell your doctor if you are attempting or anticipating attempting conception with a female partner since testosterone medication can diminish sperm production.

Inadvertent transfer

Testosterone can be inadvertently transferred from your body to others. This can happen if other people come into contact with the skin area where the testosterone was applied, especially if it was recently applied or is uncovered. You can reduce the risk of inadvertent transfer by covering the area of application with clothing. Wash your hand with soap and water immediately after applying medication to yourself. Inadvertent transference can be especially problematic when it involves women or children. If a woman or child (or any unintended person) comes into contact with the gel, she or he needs to wash the skin with soap and water. Testosterone containers should be closed and kept in a safe place that is inaccessible to children and others that may purposely or accidentally use it. If a woman who may have come into contact with testosterone develops acne or hair growth on new areas of her body, she should contact her doctor immediately. If a child who may have come into contact with testosterone develops enlarged genitals, increased erections or sexual desire, or aggressive behavior, contact the child’s doctor immediately. Women who are, or may become, pregnant and may have been exposed to topical testosterone should be made aware that there is risk to the fetus and contact their doctor immediately.

Possible side effects

Tell your doctor if you experience any of the following symptoms in a severe and/or persistent manner: breast tenderness and/or enlargement, acne, diminished sexual drive, skin irritation or dryness or redness, hair thinning or loss, mood changes including depression, diarrhea, or teary eyes.

Seek medical attention immediately if you experience any of the following serious symptoms: shortness of breath, chest pain, lower leg pain or swelling or redness, slow or difficult speech, weakness or numbness of an arm or leg, , dizziness or faintness, difficulty urinating, nausea or vomiting, swelling of ankles or feet or hands, erections that last too long, or yellowing of the eyes or skin.

The Food and Drug Administration (FDA) has concluded that there is a possible increased risk of cardiovascular events associated with testosterone use. Some studies that included aging men treated with testosterone have reported an increased risk of heart attack, stroke or death associated with testosterone treatment while other studies did not. FDA has also stated that the efficacy and safety of testosterone have not been established for treating age-related low testosterone levels, even if a man’s symptoms seem related to low testosterone.

PHOSPHODIESTERASE TYPE 5-INHIBITOR (PDE5i) TREATMENT (SILDENAFIL OR TADALAFIL)

Special precautions before using PDE5i

Tell your doctor if you have a known or suspected allergy to PDE5i or other medications. Tell your doctor about all your prescription and non-prescription medications (including supplements) that you take or are planning to take. Tell your doctor if you have a history of cardiovascular, pulmonary veno-occlusive, or retinal disease. Tell your doctor if you use drugs commonly called “poppers,” such as butyl nitrite or amyl nitrite. Tell your doctor if you are taking isosorbide dinitrate, isosorbide mononitrate, nitroglycerin, ritinovir, riociguat, ketoconazole, itraconazole, other medications to treat erectile dysfunction including intracavernosal injections. Tell your doctor if you have difficulty briskly walking up two flights of stairs. Tell your doctor if you have a history of priapism, prolonged erection or sickle cell trait or disease. This medication is not for use in women or children.

Possible side effects

These medications can cause dizziness. Avoid driving or other tasks that require alertness until you have experience with how this medication affects you. Get up slowly from a lying or seated position to reduce the risk of dizziness. Common side effects include facial flushing, headache, heartburn, muscle aches, or nasal congestion. Seek immediate medical attention if you have signs of an allergic reaction including hives, itching, wheezing, peeling skin, fever, tightness in the chest or difficulty swallowing or swelling of the mouth or tongue. Seek immediate attention if you experience chest pain or pressure, fast or irregular heartbeat, vomiting or severe nausea, or onset of weakness or drooping on one side of your body. Seek immediate medical attention if you have a change in vision, ringing in the ears, or any other changes related to hearing. Very rare severe problems have been associated with these medications, in some cases causing death. Although it has not been definitively established that this medication caused these problems, it is possible; these include severe vision problems, tonic-clonic seizures, severe increase in blood pressure and/or stroke or heart attack. This medication type does not stop the spread of sexually transmitted diseases including HIV and hepatitis. Discuss safer sex practices with your doctor. This medication has been associated with priapism, or prolonged rigid penile erection of > 4 hours (even in the absence of sexual stimulation or activity). Priapism is a condition that causes penile pain and, left untreated, can lead to severe permanent erectile dysfunction. Seek immediate medical attention if you ever become concerned about a prolonged and/or painful erection of any duration (even less than 4 hours).

Further Acknowledgements

You understand that under applicable state laws, Fountain is required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault. You hereby consent to the use of telehealth to examine, consult, diagnose, or treat you and you understand that you may seek in-person care or follow up care should you so choose. You may also request a video consultation through the Platform. You consent to Fountain (i) providing copies of your medical records to your primary care physician for Services rendered through the Platform; (ii) you give access to your provider to retrieve and view prior medication history that may be available in the Platform; and (iii) consent to receive automated and/or live text and voice reminders and messages from the Platform at your listed phone number as consistent with applicable law (to which you have the right to opt-out of going forward). If you would like to have your records sent to your primary care physician, please provide your primary care physician’s information to your doctor at the time of the visit You understand that this informed consent will become a part of your medical record.