Telehealth Consent

1. Purpose & Scope

SurgePHT LLC ("SurgePHT," "we," "us") facilitates access to licensed healthcare providers ("Providers") who deliver telehealth consultations through SurgePHT Health's platform. These services are limited to health optimization, including but not limited to hormone therapy, peptide therapy, weight management, and metabolic wellness. SurgePHT is not a primary care provider, hospital, or emergency service.

2. Nature of Telehealth Services

• Telehealth consultations may differ from in-person visits; a physical exam may not be possible.
• Technical difficulties may interrupt or prevent a consultation.
• Not all health conditions are appropriate for telehealth.
• A telehealth Provider-patient relationship is not a substitute for ongoing primary care.

3. Consent to Receive Telehealth Services

• You voluntarily consent to participate in telehealth consultations through SurgePHT's platform.
• You have truthfully disclosed your health history, medications, allergies and other relevant information.
• Withholding or misrepresenting information may result in inappropriate recommendations.
• Providers may decline to prescribe or refer you to in-person care at their clinical discretion.
• No prescriptions or specific outcomes are guaranteed.

4. Risks & Limitations

• Inability to perform physical examinations may limit diagnosis of certain conditions.
• Delays in information transmission due to technology failures could affect care.
• Security protocols are in place, but no electronic transmission is completely without risk.
• Providers may need to refer you to in-person care if telehealth is not sufficient.

5. State-Specific Availability

SurgePHT's telehealth services are only available in states where our affiliated Providers hold active, valid medical licenses. Availability may expand as our provider network grows. If you are unsure whether services are available in your state, contact us at support@surgepht.com before enrolling.

6. Emergency Disclaimer

SurgePHT is not an emergency service. If you are experiencing a medical emergency - including chest pain, difficulty breathing, stroke symptoms, severe bleeding, or thoughts of harming yourself or others - call 911 immediately or go to the nearest emergency room. Do not use SurgePHT's platform or messaging system to request emergency care.

7. Provider-Patient Relationship

A telehealth consultation through SurgePHT's platform creates a limited provider-patient relationship for the specific purpose of health optimization services. It does not constitute an ongoing primary care relationship and may be terminated by the Provider at any time if clinically appropriate.

8. Data Privacy & Security

All health information you provide is handled in accordance with our Privacy Policy and applicable HIPAA regulations. SurgePHT uses HIPAA-compliant technology platforms to store and transmit PHI. Consultations are not recorded without your explicit consent. Third-party service providers with access to PHI are bound by BAAs.

9. Withdrawal of Consent

You may withdraw this consent at any time by contacting us at support@surgepht.com or by canceling your membership. Withdrawal will not affect the lawfulness of any services already rendered.

10. Limitation of Liability

To the fullest extent permitted by applicable law, SurgePHT LLC and its affiliated Providers and technology partners shall not be liable for any indirect, incidental, special, or consequential damages arising out of telehealth services, including outcomes related to delayed diagnosis, technical failure, or treatment decisions made in reliance on incomplete information provided by the Patient.

11. Initial Intake & Follow-Up Consent

I acknowledge and understand that:

• Evaluation will be conducted remotely via video, phone, or digital communication.
• The Provider will rely on my self-reported medical history.
• The telehealth consultation does not guarantee clearance for medication.
• No in-person physical examination will be performed as part of this consultation.
• My medical information may be stored electronically for record-keeping.
• My consultation is confidential and protected under HIPAA.
• I must take precautions to ensure privacy on my end (e.g., using a secure connection).
• I am not obligated to proceed with telehealth-based evaluation if I prefer in-person care.
• My membership includes medical review, Provider support, messaging and treatment fulfillment if approved.
• Follow-up check-ins are required every 3 months before additional treatment may be approved.
• Any required lab tests or additional evaluations are my responsibility.

12. Contact

If you have questions about this Telehealth Consent, contact us at support@surgepht.com.