ACKNOWLEDGEMENT AND GENERAL CONSENT TO TREAT

I hearby authorize medical evaluation, diagnosis, physical examination, laboratory  testing, counseling and treatment or procedures at Evivia.

Evivia’s services include, but not limited to, some of the following:

Medical evaluation, physical examination, diagnosis and treatment (including  prescribing medications when appropriate) for common illnesses such as common cold,  flu, ear, eye, sinus, and bronchial infections;

Laboratory testing and medical tests;

Treatment of minor abrasions and skin conditions;

Sports and college physicals;

Occupational physicals;

Wellness services designed to help patients identify lifestyle changes needed to improve  their current and future health, including screenings and monitoring for diabetes, high  blood pressure, high cholesterol, and programs for weight loss.

Use or Disclosure of Health Information

Evivia may use or release your health information to other health care providers and  their staff for treatment purposes, to third party payors and other third parties as  necessary for Evivia to obtain payment for services you have received, or for Evivia  health care operations (such as administration and quality assurance). Evivia may also  seek to obtain your electronic health record information from other providers, or  through Health Information Exchanges, in order to provide health care services.  Additional information regarding the use and disclosure of your health information can  be found in the Notice of Privacy Practices. Please let your practitioner know if you have  any questions or concerns.

The information may be used for appointment scheduling, chart review, health  information sharing, diagnosis, therapy, remote prescribing, follow-up and/or  education, and may include any combination of the following: client health records, live  two-way audio and/or live audio-video output data from health devices and sound and  video files, text, messaging, transmission of medical images and/or data transfer.

I understand and acknowledge that my information that I provide through all  communications will result in the creation of a visit record in the electronic medical  record of the health care provider.

Electronic health record: all online visits, online forms, and in-person visits use stored  electronic health records. This allows health care providers using this record to store,  update and use my health information when needed at the time I am seeking care. The  electronic health record allows better access to my health information, leading to better  coordination and quality of care. This shared electronic health record is a secure  system.

I further understand that my healthcare information may be shared in the following  circumstances: a. when a valid court order is issued for medical records b. reporting  suspected abuse, neglect, or domestic violence c. preventing or reducing a serious  threat to anyone’s health or safety d. if the federal and/or state laws requires the  health care provider to report health care related information.

I understand that it may become necessary to use and release your protected health  information to financial parties, credit card entities, banks, and financig companies to  facilitate your payment or when they request such information to resolve a chargeback  process.

I acknowledge that any care provider who uses the shared electronic record may access  and use my health records as needed to provide treatment (including coordinating my  care) and to improve the quality of care.

I understand that making a request for treatment by completing and submitting any of  the online forms, sending online messages to a health care provider, paying for  services, providing photos and/or initiating chat does not create a duty of care or create  a doctor-patient relationship.

I understand that the provider’s duty of care does not begin at the point of me  answering questions or making payment or starting a video visit but at the point at  which the health care provider accepts the duty of care.

I acknowledge that I will answer questions truthfully and that if I do not understand a  question I will stop using all online forms, online visits, telemedicine consultations, and  all communications. I acknowledge and agree that I am solely responsible for ensuring  that the information submitted for the visit is accurate, complete and current. I  understand that the health care provider will rely on this information to diagnose and  prepare a treatment plan for my medical condition and my failure to provide accurate,  complete and current information may lead to a delay in my treatment or a  misdiagnosis.

I provide consent to receive e-mails, calls and texts and health-care related information  from or on behalf of Evivia, Eviviacare.com or any of its affiliates at the phone number  or e-mail that I provided. Consent is not a condition of purchase and make be revoked  at any time. Your carrier’s message and data rates apply.

Patient Financial Responsibility

You are responsible for paying for services in full at the time they are provided.

Services rendered are non-refundable and are not eligible for payment challenges. I  agree that I will not challenge such credit, debit, or financing card payments once the  services are provided. I agree that the credit card challenge is irrevocable.

No-Show, Late Arrival, Refund and Cancellation Policy

I agree to be charged a full price for all medical services. I acknowledge that I am  entirely responsible for paying the full cost of services via credit card, an online  payment method or cash.

I agree that there will be no refund if I cancel and/or reschedule my appointment with  less than 24 hour written notice to practice.

I agree that there will be no refund if I do not show up for my appointment “A no  show.” A no-show is when a client misses the scheduled appointment without  cancelling.

I agree and understand that my appointment may be rescheduled, if available, in the  event I arrive late for my appointment “Late Arrival.” Late Arrival means arriving at the  clinic 15 minutes after the scheduled appointment time. I agree that there will be no  refund in the event I arrive late for my appointment and no other appointments are  available.

I will email info@eviviacare.com as soon as I know I am not able to make the  appointment. I understand that the only way to cancel and/or reschedule the  appointment is via providing a written notice to cancel to email info@eviviacare.com.