Telehealth Informed Consent

— 1. Who Provides Your Care

Your medical care is provided by an independent, physician-owned medical practice operating under the Go Clinic brand (your “Practice”). The specific Practice responsible for your care depends on the state where you are located and is identified to you at your visit. Your treating clinician is licensed in the state where you are located at the time of your visit. Go Clinic MD, LLC provides administrative and technology support to your Practice and does not itself provide medical care.

— 2. What Telehealth Is

Telehealth means receiving health care from a clinician at a different location using secure electronic communication — typically live two-way audio and video, and, where clinically appropriate and permitted in your state, audio-only or asynchronous (store-and-forward) communication. Your visit may include evaluation, diagnosis, treatment recommendations, prescriptions where appropriate, therapy services, and coordination of in-person testing or care near you. Information exchanged may include your medical records and history, medical images and test results (such as VNG and neurocognitive testing), live audio and video, and data or files from medical devices. Your care team may include neurologists, physical medicine & rehabilitation (PM&R) physicians, nurse practitioners, physician assistants, neuropsychologists, and vestibular, physical, occupational, and speech therapists.

— 3. This Is Not a Substitute for Your Other Care

Telehealth care from your Practice does not replace a relationship with a primary care provider and does not coordinate all of your medical care outside these services. Continue to see your primary care provider and other treating professionals as recommended, and seek emergency or follow-up care whenever it is needed or advised by your clinician. You may form an ongoing treatment relationship with members of your care team.

— 4. Expected Benefits

Expected benefits include, but are not limited to, access to specialist evaluation without travel; earlier initiation of guideline-based care; coordination of your care team and records in one place; and continuity from evaluation through return to work, school, and activity. No specific outcome or result can be guaranteed or assured.

— 5. Possible Risks and Limitations

As with any medical care, telehealth carries potential risks, including but not limited to: information transmitted may occasionally be insufficient (for example, poor image resolution) for your clinician to make fully informed decisions; technology can fail or a connection can drop, which may delay evaluation or treatment — if a visit is interrupted, we will reconnect or reschedule and may contact you by phone; despite reasonable security measures, there is a rare risk that information could be accessed without authorization; and, in rare cases, a lack of complete medical records may contribute to a treatment or judgment error, such as an adverse medication interaction or allergic reaction. A physical examination cannot be fully performed remotely; if your condition requires in-person evaluation, testing, or treatment, your clinician will tell you and help arrange it. Because clinician licensure is state-specific, you may be asked to confirm your location at each visit.

— 6. Privacy and Confidentiality

The laws that protect the privacy and confidentiality of medical information apply to telehealth. Your health information is protected health information under HIPAA and applicable state law and is used and disclosed as described in the Notice of Privacy Practices. Information that identifies you will not be disclosed to researchers or other entities without your consent, except as permitted or required by law. Visits are conducted over encrypted connections, and the systems used include safeguards to protect the confidentiality and integrity of your information.

Recording and AI-assisted documentation

Every visit is recorded. An artificial intelligence (AI) tool uses the recording to draft your visit note. Your clinician reviews the draft for accuracy, edits it, and signs it; the recording is deleted once the note is finalized. AI tools help with documentation only — your clinician, not a computer, makes every diagnosis and treatment decision.

Anyone you invite to join your visit is also recorded; tell them before they join. Take your visit from a private location; anyone present with you can hear your health information.

— 7. Emergencies

Telehealth services are not for emergencies. If you experience worsening or severe headache, repeated vomiting, seizure, slurred speech, weakness or numbness, unusual drowsiness or confusion, or any loss of consciousness after a head injury, call 911 or go to the nearest emergency department immediately. At the start of care your Practice will confirm your physical location and a local emergency contact so help can be directed to you if an urgent situation arises during a visit.

— 8. Your Acknowledgments and Agreement

By using these services, you understand and agree that:

• Your participation in telehealth is voluntary. You may withhold or withdraw your consent at any time, without affecting your right to future care; withdrawing consent may limit your ability to use some parts of the service.
• You may ask questions about telehealth, your diagnosis, and your treatment options at any time.
• You may inspect and obtain copies of the information recorded in your telehealth record, for a reasonable, cost-based fee.
• At your request, we can send a copy of your telehealth encounter records to your primary care provider or other treating professionals.
• Alternative methods of care may be available to you, and you may choose one or more of them at any time.
• Your clinician may determine that telehealth is not appropriate for some or all of your care and may decline to provide it.
• If someone other than your clinician is present to help with the technology or to take notes, that person is trained and required to keep your information confidential. You will be told they are present, and you may ask them to leave, ask that sensitive details be omitted, or end the visit at any time.
• Telehealth may involve electronic communication of your information to other health care professionals, who may be located in other areas, including out of state.
• Your clinician may perform an examination through these technologies.
• It is your responsibility to tell your clinician about other electronic interactions concerning your care that you have with other providers.

— 9. State-Specific Provisions

Some states require additional or differently-formatted telehealth consent. Where your state requires specific language, the state-required form supplements or replaces this general consent and is presented to you at intake.

Texas patients — Notice Concerning Complaints

The following notice is provided to patients located in Texas, as required by the Texas Medical Board.

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, surgical assistants, medical radiologic technologists, non-certified radiologic technicians, respiratory care practitioners, medical physicists, and perfusionists, may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 1801 Congress Avenue, Suite 9.200, P.O. Box 2018, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information, please visit our website at www.tmb.state.tx.us.

— 10. Consent and Acknowledgment

By checking the box below (or signing), I confirm that: I have read and understood this consent; I have had the opportunity to ask questions and they have been answered to my satisfaction; I understand the benefits, risks, and limitations of telehealth; I understand who provides my medical care as described in Section 1; I understand that visits are recorded and that AI-assisted documentation is used as described in Section 6; and I voluntarily consent to receive care via telehealth from my Practice and authorize my Practice and its clinicians to use telehealth in my evaluation and treatment.