CLIENT CONSENT TO TELEHEALTH

LUMA Health LLC and its affiliates (“LUMA Health”, “LUMA”, “we,” or “us“) owns and operates this website located at https://www.luma.health (collectively, the ”Platform“). Your access and use of the Platform, any part thereof, or anything associated therewith, including its content (“Content“), any products or services provided through the Platform or otherwise by LUMA Health, and any affiliated website, software or application owned or operated by LUMA Health (collectively, including the Platform and the Content, the “Service“) are subject to this Consent to Telehealth unless specifically stated otherwise. Capitalized terms not otherwise defined in this Consent to Telehealth have the same meaning as set forth in the LUMA Health Privacy Policy and Terms of Service.

By signing this form, clicking a checkbox, or otherwise participating in any services offered by LUMA Health, I voluntarily understand, acknowledge, and agree to the following with respect to medical services rendered by LUMA Health's contracted physicians (each a “Physician”), associates, technical assistants, agents, and other healthcare providers (collectively, “the Practice”), and any and all employed or contracted support staff, health coaches, admins, or operations associates. Contracted physicians are independent medical professionals individually licensed, operating, and making independent medical judgment to serve patients utilizing The Platform. LUMA Health does not practice medicine.

I request, voluntarily consent to, and authorize the services and treatment described herein, including without limitation telemedicine consultation, preventive medicine services, sexual wellness services, diagnostic testing, personal training or lifestyle coaching, as well as any additional services that are advisable in a Physician’s professional judgment that may be rendered.

I understand that no promises or expectations have been made to me about the results of any treatments or services.

I understand that I have read and understood each of the provisions appearing on this consent form. I also acknowledge that I have had the opportunity to ask any questions that I may have, and by my electronic agreement, I consent and agree to all provisions herein both individually and collectively.

I consent and agree that it is my duty to read all information provided to me by my assigned physician or provided to me by the platform, including but not limited to dosing guidelines, medication information, contraindications, dietary and lifestyle support literature, terms of service, and more.

The consent and any/and all updates to it will remain fully effective until it is revoked in writing. I have the right at any time to discontinue services.

Not Primary Care; Limit of Role

The Platform facilitates interactions by Providers (or the Practice), who are acting in a specialist, supportive, consultative capacity and not as a primary care physician and do not provide emergency care. Accordingly, The Practice is not replacing care currently provided to me by other physicians, such as my current primary care physician, internist, urologist, cardiologist, gastroenterologist, or other specialty care provider. The Practice has advised me that the Practice does not admit patients to the hospital or treat hospitalized patients, and that I should maintain a relationship with a physician who is available to provide emergent and urgent care. The Practice does not provide immediate on-call services.

IF I ENCOUNTER A MEDICAL EMERGENCY, I WILL CONTACT 911 OR REPORT TO A HOSPITAL EMERGENCY DEPARTMENT. If at any time I feel my condition has progressed, worsened, or has not improved over a long period of time, I agree to go to the nearest emergency room immediately.

I UNDERSTAND THAT THE PRACTICE IS CASH PAY ONLY AND DOES NOT SUBMIT CLAIMS OR BILLS FOR REIMBURSEMENT BY INSURANCE OR MEDICARE. I ACKNOWLEDGE AND AGREE THAT THE SERVICES MAY NOT BE COVERED BY INSURANCE OR MEDICARE.

I AGREE THAT ALL PERSONAL INFORMATION I PROVIDE, INCLUDING MEDICAL INFORMATION, IS TRUTHFUL, HONEST, AND ACCURATE; AND I EXPRESSLY WAIVE AND RELEASE ANY CLAIMS I MAY HAVE AGAINST THE PRACTICE AND THE PHYSICIAN FOR INJURIES OR DAMAGES THAT ARISE OUT OF UNTRUTHFUL, DISHONEST, OR INACCURATE INFORMATION THAT I PROVIDE.

Telemedicine Consent: I understand that the Platform and the Practice may use telemedicine mechanisms to consult for, discuss, and recommend treatment. I also understand that telemedicine involves the delivery of clinical health care services by electronic communication (including two-way audio-visual communication and asynchronous messaging), as defined by applicable law. Use of telemedicine services can result in benefits such as improved access to care and decreased exposure to community spread and person to person spread of illnesses. I acknowledge that use of telemedicine via the Service is adequate in establishing a valid provider-patient relationship and delivering the standard of care. Potential risks include gaps of failures in communication, complicating healthcare decision-making, notwithstanding reasonable efforts to ensure the quality and reliability of transmitted information. There may be limitations to image quality or other electronic problems that are beyond the control of the Practice and the Platform. Despite reasonable security measures, online communications can be forwarded, intercepted, or even changed or falsified without my knowledge. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I understand and agree that during my telemedicine consultation, in addition to the Physician conducting the consultation, another Physician may be observing my consultation for training purposes. I fully understand, request, and agree to participate in telemedicine services.

Prescription & Recommendation Policy: I understand that there is no guarantee a prescription or recommendation will be given by a Physician. Physicians shall use their own discretion and professional judgment to prescribe and/or recommend medications and protocols, or certain other drugs which may be harmful because of their potential for abuse. Physicians reserve the right to deny care for actual or potential misuse of medical care and any associated prescriptions and recommendations. I agree that any prescriptions or recommendations that I acquire from a Physician or the Practice will be solely for my individual personal use. I agree to fully and carefully read all provided information and labels and to contact a Physician or pharmacist if I have any questions regarding the prescription or the recommendation.

For any therapies that are recommended, I understand that I have the full right to purchase these therapies from any source of my choosing. I acknowledge and agree that LUMA Health and its contracted physicians take no responsibility for the sourcing, quality, purity, or efficacy of any peptides, supplements, or protocols obtained independently from third-party suppliers.

Informed Consent of Off-Label Treatment

FDA Approval Status

The treatment you might be receiving may have not been approved by the FDA to treat my condition. The treatment you might be receiving may not have been approved by the FDA to treat any condition. Even if the ingredients of the treatment are FDA approved, you acknowledge that compounded medication is not specifically FDA-approved due to its custom formulary nature.

Peptides and Wellness Therapies

I understand that certain therapies recommended or prescribed by the Practice may include peptides and wellness therapies that are not reviewed or approved by the U.S. Food and Drug Administration (FDA) at all for human consumption. These therapies may be considered experimental or used off-label. I acknowledge that I have been informed of this status and accept any risks associated with such therapies.

Off Label and No Label

When a drug or device is approved for medical use by the Food and Drug Administration (FDA), the manufacturer produces a “label” to explain its use. Once a device/medication is approved by the FDA, physicians may use it “off-label” for other purposes if they are well informed about the product, base its use on firm scientific method and sound medical evidence, and maintain records of its use and effects. Sometimes, Providers may also prescribe or recommend medications and protocols that are not approved by the FDA, and I acknowledge and assume any responsibility for using them.

Email, Phone, & Text Consent:

If at any time I provide an email or telephone number(s) at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email and/or telephone number(s) from the Practice via email, text message, push notification, chat, and/or voicemail message. I agree that all agreements and consents can be signed electronically and all notices, disclosures, and other communications that the Practice provides to me electronically satisfy any and all legal requirements that such notices and other communications be in writing.

Duty to Inform:

I also understand it is my responsibility to keep the Practice informed of the name and contact information of my primary care physician and treating specialists, of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions.

Physical Exam Acknowledgment:

I have had an annual physical exam with my primary care physician of record.

Alternative Approaches:

As alternative approaches to my healthcare, the Practice encourages me to speak with and consider the advice of other physicians or appropriate healthcare practitioners regarding my overall care.

Miscellaneous

My Participation:

I understand that I am responsible to disclose to the Practice all medication, care, treatment, diagnoses, and assessments that I receive elsewhere and am responsible to provide medical records from other providers to ensure that care is coordinated and compatible. Medical records can only be released with my authorization. I will need to obtain any records and/or labs that I would like the Practice to review.

Off-Label or Unapproved Use:

I understand that the Practice may prescribe medications for uses other than those indicated by the drug manufacturer and approved by the federal Food and Drug Administration (off-label use). I understand that the Practice may recommend treatments for uses other than those indicated that are not approved by the federal Food and Drug Administration for human use of any kind, that are considered experimental. I voluntarily consent to all of these recommendations and prescriptions and have the ability to deny such recommendations. In such a case, no one can be fully aware of all possible side effects and complications.

The details of such off-label or non-approved use including expected benefits, material risks, and alternatives have been explained to me in terms I understand. I have informed or will inform the Practice of all known allergies, and of all medications I am currently taking via a health history questionnaire.

No Claims or Guarantees:

I understand that the Practice makes no representations, claims, or guarantees that my medical problems or conditions will be cured, solved, or helped by undergoing treatment by the Practice.

Referrals:

I understand that the Practice’s treatment may include recommendations that I seek other types of treatment from other health professionals who are not affiliated with the Practice. I understand that the Practice does not supervise these professionals and is not clinically or legally responsible for them. I understand that they are not the Practice’s employees and that they will bill separately for their services.

Assumption of Risk; Indemnity:

I choose to receive care that may involve clinical innovation and/or may differ from conventional medicine. Accordingly, I knowingly, voluntarily, and intelligently assume all risks involved in the same.

As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend the Practice, the Physician, LUMA Health LLC, and all of their respective predecessors, successors, assigns, parent, subsidiaries, partners, employees, agents, officers, directors, representatives, attorneys, administrators, contractors, subcontractors, and/or consultants, and each of them (collectively, “Indemnitees”), from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the treatments or services described herein. Further, I agree not to pursue a frivolous claim against any of the Indemnitees, merely because I am dissatisfied with the results of the above treatments or services.

AUTHORIZATION FOR LIMITED RELEASE OF PROTECTED HEALTH INFORMATION:

I hereby authorize the Practice and/or the Platform to send an electronic laboratory requisition to me via email at the email address I provided to the Practice for the purpose of helping to facilitate an optimal laboratory experience when I visit the laboratory. This authorization is in effect until I receive the requisition from the Practice via email, at which point it will expire. I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. If I consent to this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed. I have the right to receive a copy of this authorization. I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.

I hereby authorize the Practice and/or the Platform to utilize redacted, deidentified or partial information of my PHI as needed to conduct normal business activities and any activities that could reasonably be defined as such. I have the right to withdraw permission for the release of my information. I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.

POLICIES

By signing this form, I acknowledge that, with respect to services rendered by the Practice or accessed through the Platform, I understand the following:

Cancellation Fee:

You will only be charged after you are approved for a prescription or recommendation. You may cancel your order with no charge before your medical history forms are approved and notice is sent.

No Refunds after Order:

The Practice or Platform does not offer any refund of any kind for orders that have been placed with the Pharmacy or with Third Party Suppliers. Each order is custom-made for each patient, which is why we cannot offer refunds once the order has been placed.

Payments, Recurring Payments, Subscriptions:

I understand by providing your payment information to the Practice or Platform you authorize the Practice or Platform to charge or facilitate the charge of such payment information, including for automatic recurring payments, for all services and/or treatments. Certain services are offered on a subscription basis. For subscription-based services, your chosen payment method will be charged at regular intervals automatically as described for that service. You understand that when joining or signing up for subscription-based services, in which three months of products and/or medications are dispensed to you, you agree to be bound to at least a three-month subscription. If you cancel your subscription and/or terminate the payment method (and do not replace the payment method) for such subscription, you agree that you are responsible and obligated to pay for the remainder of the payments for such three-month subscription. Subject to the foregoing sentence, you may cancel a subscription at any time up to forty-eight (48) hours before the applicable monthly processing date of your subscription by emailing service@luma.health. You understand that the cost of services, including medications, are final and not refundable (except as otherwise set forth herein). You understand you will not receive refunds for any treatments or medications, including unused or unopened treatments and medications, unless otherwise set forth herein. You agree that the Practice or Platform may store any payment information that you provide for the purposes of recurring payments that you have chosen to participate in as part of any membership or subscription programs or plans.

If you are delinquent on any payments, the Practice or Platform reserves the right to discontinue services. The Practice or Platform may use third-party services for the purpose of facilitating payment and the completion of the purchases for services rendered by the Practice or Platform in conjunction with the services. By submitting your payment information, you grant the Practice or Platform the right to provide information to these third parties. You represent and warrant that (i) any payment information you supply is accurate, true, and complete, (ii) any charges incurred for services will be honored by your credit/debit card company or bank, (iii) you will pay all charges incurred by you including applicable taxes, and (iv) the payment card is in your name and you are authorized to use such card for purchases.

Electronic Signatures and Acknowledgement:

I agree that electronic signatures below or clicking a checkbox are the legal equivalent of manual signatures on this Agreement, and manifest consent to be legally bound by this Agreement’s terms and conditions.

Digital Records:

Provider and Platform may store medical and office records digitally. While the Practice or Platform will make reasonable efforts to keep the data secure according to legal requirements, and maintains the privacy and confidentiality of patient data, I understand that no system is 100% secure. I agree that LUMA Health LLC and/or the Practice or Platform may de-identify my information such that it is no longer considered protected health information or personally identifiable information and may convey, sell, transmit, or provide such de-identified information to third parties.

Office Insurance Practices and Patient Financial Responsibility

Payment:

The Practice or Platform accepts credit cards only and is exclusively cash pay. I agree that the Practice or Platform may store any payment information that I provide for the purposes of recurring payments that I have chosen to participate in as part of any membership or subscription programs or plans. The practice and platform are under no obligation to provide backup information for the use of insurance reimbursement, participation in HSA/FSA plans, or any other reimbursement or tax-advantaged programs.

No Participation in Insurance Plans:

The Practice or Platform is an out-of-network provider for services within this Practice; the Practice or Platform does not participate in any insurance panels and does not accept assignments from any insurance company. Consequently, I am responsible for payment in full and all charges as determined by the Practice or Platform.

No Responsibility To Determine Eligibility for Benefits:

The Practice or Platform is not responsible for determining eligibility for benefits or for assisting me with collecting insurance benefits and has no responsibility to correspond with or telephone or email any insurer with which the Practice or Platform is an out-of-network provider.

My Financial Responsibility:

I am financially responsible for any charges for services. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for the Practice or Platform to take action to secure payment of an outstanding balance.

Charges:

The Practice or Platform may recommend additional specific products or services such as prescriptions, blood or urine tests, or supplements that may be additional costs.

Physician-Patient Arbitration Agreement

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Wyoming law, or another state to which the Practice and its independent physician is licensed in at the time of care, and not by a lawsuit or resort to court process except as Wyoming law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Physician-Patient and Platform-User Arbitration Agreement

Article 1: Agreement to Arbitrate:

It is understood that any dispute, including but not limited to disputes regarding medical malpractice (as to whether any medical services rendered under this contract were unnecessary, unauthorized, or improperly, negligently, or incompetently rendered) or any services, communications, advice, or transactions facilitated by or through the Platform, will be determined by submission to arbitration as provided by Wyoming law, or another state to which the Practice and its independent physician is licensed in at the time of care, and not by a lawsuit or resort to court process except as Wyoming law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated:

It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the Practice and/or services or access provided through the Platform, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, the Practice, the Platform, and the Practice’s or Platform’s partners, associates, association, corporation or partnership, and the employees, agents, and estates of any of them, must be arbitrated, including, without limitation, claims for loss of consortium, wrongful death, emotional distress, or punitive damages. Filing of any action in any court by the Practice or Platform to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice or service-related claim.

Article 3: Procedures and Applicable Law:

A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty (30) days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty (30) days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of Wyoming law applicable to health care providers and service providers shall apply to disputes within this arbitration agreement.

Article 4: General Provisions:

All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Wyoming statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the Wyoming Code of Civil Procedure provisions relating to arbitration.

Article 5: Retroactive Effect:

If the patient or user intends this agreement to cover services or use of the Platform rendered before the date it is signed (including, but not limited to, emergency treatment), the patient should initial below:

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

NOTICE:

BY SIGNING THIS AGREEMENT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE OR ANY PLATFORM-RELATED SERVICES DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS AGREEMENT.

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How to Contact Us:

service@luma.health

www.luma.health

LUMA Health LLC

30 N Gould St Ste R

Sheridan, WY 82801