Introduction

The purpose of this consent form is to provide you with information about Telehealth and to obtain your informed consent for healthcare services delivered by eye care providers through online platforms owned and operated by EyeQue or its subsidiaries (“EyeQue”). EyeQue is not a healthcare provider.

Telehealth involves the use of electronic communications (e.g. secure video conferencing, phone calls, text messaging) to provide healthcare services remotely. This includes consultation, diagnosis, treatment, education, and follow-up care. Telehealth allows you to receive care without needing to visit a healthcare facility in person. Services available through the EyeQue platform include refraction services and non-urgent eye related concerns.

If you believe your eye condition is an emergency, please call your eye care provider, head to the nearest emergency room, or call 911.

Please read this form carefully. Your digital signature below indicates that you understand and agree that your eye care provider will provide you healthcare services via Telehealth using the platform.

Benefits of Telehealth Services

Receiving eye care services through Telehealth technology has many benefits, including improved access to eye care, convenient appointment times, and receipt of care from the comfort of home or other convenient location.

Potential Risks

By agreeing to receive eye care services through Telehealth technology you acknowledge the following:

1. Your provider uses a technology service called EyeQue. EyeQue’s Telehealth technology is designed to protect patient privacy. However, as in all healthcare situations, it is possible that security protocols could fail which may expose your medical information.

2. Because Telehealth services are performed remotely, providers may be unable to perform a full physical examination or assessment. This service is not a replacement for a comprehensive eye examination.

3. If a comprehensive eye examination is needed, or if certain symptoms or conditions are discovered, then the provider may advise that you should seek an in-person examination. Not all conditions can be evaluated or treated by Telehealth.

4. In rare instances, information transmitted (e.g., poor resolution of images, audio failure, etc.) may not be sufficient to allow for appropriate medical decision making by the health care provider and may cause delays or disruptions in your services. If this happens, an additional attempt may be needed to complete the service.

5. The inability to conduct tests or assess vital signs in person may prevent healthcare providers from providing a diagnosis, treatment, or from identifying a need for emergency medical care.

6. A lack of access to all your medical records may result in gaps or errors. It is important that you provide complete and accurate information to your eye care provider.

7. Data and information stored and shared electronically, such as through email or text, may be more susceptible to unintended disclosure of health information or other personal information to third parties.

Patient Rights

By indicating below that I accept this consent, I agree that I understand that I have the right to:

1. Receive clear information about my care.

2. Choose whether to participate in Telehealth or seek in-person care.

3. Withdraw my consent to Telehealth at any time without affecting my right to future care or treatment.

Patient Responsibilities

I understand that eye care services and treatment are the result of a collaborative relationship between me and my eye care provider. By using EyeQue services I agree that I will:

1. Provide accurate and complete information about my health history, along with any relevant conditions or treatments.

2. Promptly pay for the services I receive. I understand that EyeQue will not bill insurance, and I hereby release EyeQue to charge me directly for the services I receive via the EyeQue Telehealth service.

3. Review and be subject to EyeQue policies and procedures. I understand I can find those policies at Terms and Conditions and Privacy Policy.

Privacy and Confidentiality

Your privacy and confidentiality are important to us. Telehealth sessions are conducted using our secure platform to protect your information and healthcare data. EyeQue and your provider will not share your information unless it is permitted or required by law.

Consent to Telehealth Services

By checking the box below and typing my full name, I acknowledge:

• I have read and understood the information provided above, including the potential benefits and risks of Telehealth eye care services.

• I have had an opportunity to ask questions about Telehealth and received satisfactory answers.

• Services provided via the EyeQue Telehealth service are not intended to treat urgent or emergency conditions. If I am experiencing a medical emergency or urgent condition, I will contact appropriate emergency response and seek care in person.

• It is my duty to provide my eye care provider with truthful, accurate, and complete information, including all relevant information regarding care that I receive or may be receiving from other healthcare providers, including other eye care providers.

• My eye care provider will assess my condition and provide eye care services, and may determine, in their sole discretion, it is appropriate to provide the services through Telehealth. By continuing to use the service, I indicate that I agree with the provider’s assessment and agree to receive eye care services through Telehealth.

• My eye care provider may, in their sole discretion, determine that my condition is not suitable for services through Telehealth, and that I may have to seek treatment from a specialist or eye care provider outside of this Telehealth service.

• I understand that no guarantees have been made to me as to the outcome or result of my use of the services.

• Services will be provided by a qualified provider, and I have access to information about the professional credentials of my provider.

• I understand and consent that any prescription or communication regarding the Telehealth visit will be provided digitally.

• I voluntarily consent to receive healthcare services via Telehealth.