TELEMEDICINE CONSENT

OAK HEALTH INSTITUTE

Telehealth Consent Form

Medical services provided by Frank J. Welch, MD PLLC

Last Updated: May 28, 2026

OUR HEALTHCARE PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE HAVING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 OR GO TO THE NEAREST EMERGENCY ROOM.

BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE, OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE.

This form covers: Consent to Telehealth, Treatment-Specific Consent, Consent to Compounded Medications, Authorization to Use and Disclose Medical Information, Consent to Text or Email Communication, and Financial Responsibility Acknowledgment.

Consent to Telehealth

Telehealth is a mode of delivering healthcare services via communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s healthcare. The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare services to you by physicians, physician assistants, and/or nurse practitioners (“Providers”) using the online platform operated on behalf of Frank J. Welch, MD PLLC.

You are reviewing and acknowledging this Telehealth Consent Form because you are seeking services from Frank J. Welch, MD PLLC (the “Practice”) utilizing telehealth technologies. Non-clinical and administrative support for the Practice is provided by Pirate Alley, LLC, doing business as Oak Health Institute (“OHI”), which operates the website and technology platform (collectively, the “Platform”) but does not provide medical care. This Telehealth Consent Form supplements but does not modify or supersede the OHI Terms of Use, Privacy Policy, or Notice of Privacy Practices.

By clicking “I consent to telehealth,” you indicate that you have reviewed this Telehealth Consent Form or had it explained to you, that you understand the risks and limitations of using telehealth technologies, that you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction, that you have been given the opportunity to exercise your opt-out rights where appropriate, and that you consent to receiving services from licensed healthcare Providers employed by or contracted with the Practice who may be located at sites remote from you. If you would like to speak to our team, please email info@oakhealthinstitute.com.

Treatment-Specific Consent

By clicking “I consent to telehealth,” you understand and agree to the following:

1. I understand that the Practice offers telehealth visits, which are conducted through videoconferencing, telephonic, and asynchronous technology, and that my Provider will not be present in the room with me.

2. I am consenting to the Practice importing and accessing my medical records and medication list, including prescription records.

3. To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Provider will similarly be in a private location. If any other individuals are present (e.g., for technological or translation assistance), I will be informed of the individual’s presence and role, and I will be given the opportunity to consent to such individual’s presence.

4. I understand there are potential risks to the use of telehealth technology, including but not limited to interruptions, delays, unauthorized access, other technical difficulties, data processing errors, AI misinterpretation, recording failures, and ambient listening inaccuracies. I understand that either my Provider or I can discontinue the telehealth appointment if the technical connections are not adequate for my visit. I AGREE TO HOLD HARMLESS THE PRACTICE AND ITS MANAGEMENT COMPANY, PIRATE ALLEY, LLC, TOGETHER WITH THEIR EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PREDECESSORS, AND SUCCESSORS, FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES OR FOR ANY ISSUES ARISING FROM THE USE OF AI TECHNOLOGIES, RECORDINGS, OR AMBIENT LISTENING SYSTEMS.

5. I understand that my telehealth visit may involve the use of artificial intelligence (AI) technologies for purposes including transcription of conversations, analysis of medical information, clinical decision support, quality assurance, and improvement of telehealth services. I understand that AI systems may process, analyze, and store information from my telehealth visit, including my voice, image, and medical information shared during the visit, and that such processing may occur in real time and/or after my visit has concluded. Information processed by AI systems will be protected in accordance with applicable privacy laws and the Practice’s privacy policies. I have the right to request information about what AI technologies are being used during my care and how my information is being processed.

6. I understand that, as part of my care, my Provider may use AI tools to assist with analyzing medical data or records, supporting clinical decision-making, generating summaries or documentation, or recommending potential diagnoses or treatment options. AI tools are intended to support, not replace, the professional judgment of my Provider. I acknowledge that my Provider will review any AI-assisted outputs before making clinical decisions, and I have the right to ask questions about how AI is used in my care and to request that AI not be used in certain aspects of my treatment, where feasible.

7. I understand that my telehealth visit may be recorded (audio and/or video) for purposes including quality assurance, provider training, clinical documentation, and care coordination. I understand that I will be notified at the beginning of any session that is being recorded. Recordings may be retained for a specified period in accordance with applicable laws and regulations and the Practice’s retention policies. I have the right to request access to recordings of my telehealth visits, subject to applicable laws, regulations, and the Practice’s policies.

8. I understand that ambient listening technologies may be used during my telehealth visit to record the encounter, and that such technologies may involve third parties contracted by the Practice. These technologies may be used to capture relevant clinical information that I share during the visit. I can request that ambient listening be disabled during portions of my visit by notifying my Provider. Information captured through ambient listening will be protected in accordance with applicable privacy laws and Practice policies. I have the right to know when ambient listening technologies are active during my visit.

9. I understand that in some cases my Provider might be a nurse practitioner or a physician assistant and not a physician.

10. I understand that I could seek an in-office visit rather than obtain care from a Provider, and I am choosing to participate in a telehealth visit. I further understand that my Provider may not have access to a complete copy of my medical records and will not have the ability to perform an in-person examination, which could result in negative health outcomes from the recommended treatment (e.g., adverse drug interactions or allergic reactions). I further understand that while using telehealth technologies may benefit me, no such benefits or specific results are guaranteed, and my condition may not improve.

11. I understand that certain technology, including the Service, may be used while still in a development phase and may contain bugs or other errors that could limit functionality, produce erroneous results, render technology unavailable or inoperable, or cause records, transmissions, data, or content to be corrupted or lost, any of which could impact the quality, accuracy, and effectiveness of the care or services I receive.

12. I understand that the delivery of healthcare services via telehealth is an evolving field and may include uses of technology different from those described in this Consent. No potential benefits from the use of telehealth or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment. My condition may not be cured or improved and, in some cases, may get worse. There are limitations in the provision of care via telehealth, and I may not be able to receive diagnosis and/or treatment through telehealth for every condition for which I seek care.

13. I agree that any information I provide as part of any telehealth visit is accurate, true, and complete.

14. I understand that my Provider may determine that a telehealth visit is not appropriate for me due to my particular health concern or other reasons related to my health status. In such a case: (i) I will receive an alert notifying me that I will be unable to use the Services for the particular issue I submitted; (ii) my request for a telehealth visit will not be submitted to my Provider; (iii) my Provider will not receive the information I submitted; and (iv) I will need to seek any needed care in another way.

15. I understand that participating in a telehealth visit is not a guarantee that I will be given a prescription, and that the decision as to whether a prescription is appropriate for my condition will be made in the professional judgment of my Provider.

16. I understand that while the Platform may make available access to certain pharmacy or diagnostic lab services, I may request to use any pharmacy or lab of my preference.

17. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.

18. I understand that Providers do not address medical emergencies via the Platform, and that the responsibility of my Provider may be to direct me to emergency medical services, such as an emergency room.

19. I, the parent or legal guardian of a minor, hereby authorize consent to any medical order, laboratory order, medical diagnosis, or treatment, and represent that I have legal authority to consent to such treatment or order.

20. I agree that Pirate Alley, LLC is a third-party beneficiary of this Telehealth Consent Form and has the right to enforce it against me.

21. I understand and agree that I give permission to Providers to use and disclose my protected health information, including my entire medical record, for the purpose of telehealth treatment.

1. If the person or entity receiving this information is not a healthcare provider or health plan covered by HIPAA, the information described above may be redisclosed to other individuals or institutions and therefore may no longer be protected by HIPAA.

2. I may refuse to agree to this authorization. My refusal to sign will not affect my payment, ability to obtain treatment, or eligibility for benefits unless this authorization is requested prior to research related to treatment or providing healthcare that is solely for the purpose of giving that information to a third party, such as to a court for a legal proceeding.

3. I may inspect or copy the protected health information to be used or disclosed under this authorization.

4. I may revoke this authorization in writing at any time by sending written notification to the Privacy Officer at info@oakhealthinstitute.com. My notice of revocation will not apply to actions taken by Providers prior to the date of receipt of the notice.

Additional Treatment-Specific Consent (Compounded Medications)

The following consent applies to patients who receive a prescription from a Provider for compounded medications, which may include hormone therapies, GLP-1 and related weight-management medications, and peptide therapies dispensed by a compounding pharmacy such as Formulation Compounding Center.

1. I understand that the FDA does not approve or review compounded products for safety, effectiveness, or quality.

2. I understand that compounding pharmacies must adhere to strict quality control standards to ensure the safety and effectiveness of the medications they prepare, and that compounding pharmacies are licensed pharmacies subject to state and federal regulations.

3. I understand that I will be provided with, and am responsible for reviewing, the safety information accompanying any prescribed medication, and that I should contact my Provider or the dispensing pharmacy with any questions.

Laboratory Products and Services

Certain healthcare services provided to you by Providers via the Service may require that you complete an at-home or in-person diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither the Practice, OHI, nor your Provider(s) can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false-negative, false-positive, or inconclusive results that could impact your Provider(s)’ ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact your Provider(s)’ ability to correctly diagnose or treat your medical conditions.

Financial Responsibility Acknowledgment

By clicking “I accept,” I confirm that the above information is true, correct, and complete to the best of my knowledge. I understand and acknowledge the following:

1. Oak Health Institute and the Practice operate on a cash-pay and membership basis. The Practice does not bill insurance, and the fees I pay are not insurance premiums.

2. I am financially responsible for all fees and charges associated with my telehealth visits, memberships, medications, laboratory tests, and any other services I receive. Services provided by outside companies (e.g., laboratory, pathology, pharmacy) may be billed separately by those companies.

3. I may submit a request to my insurance company for reimbursement on my own behalf, but the Practice and OHI make no representation or guarantee that any amount will be reimbursed, and I remain responsible for all amounts due regardless of any reimbursement I may or may not receive.

4. I authorize the Practice and OHI to use and disclose my healthcare information for the purpose of obtaining payment for services and administering my membership or account.

Consent to Text or Email Communication

By clicking “I accept,” I authorize the Practice and OHI to contact me via phone call, SMS/text message, or email at the contact information I have provided, for the purposes of appointment reminders, patient feedback requests, and general health and wellness information.

I understand and agree to the following:

• These communications may be generated in part by automated systems or artificial intelligence (AI).

• Standard messaging and data rates may apply.

• This authorization will remain in effect for future communications unless I revoke it in writing.

• I may opt out of receiving such communications at any time by following the opt-out instructions provided in each message or by contacting the Practice directly.

• Using these communication methods presents a potential security risk of unauthorized access to protected health information (PHI), and I accept this risk and consent to receiving communications through these methods.

If you prefer not to receive appointment reminders or health information via text or email, please notify us in writing or email us at info@oakhealthinstitute.com.

North Carolina Disclosures

The Practice provides telehealth services to patients located in North Carolina. I understand that my primary care provider or other treating physician may obtain a copy of the records of my telehealth encounter with my consent, and that the Practice may securely send a copy of my telehealth treatment records to my primary care provider or other treating physician upon my request. If I need assistance sending my records, I may contact the Practice at info@oakhealthinstitute.com.

Formal Complaints. If I want to register a formal complaint about a Provider, I understand that I may contact the North Carolina Medical Board, which licenses and regulates physicians and physician assistants in North Carolina, at www.ncmedboard.org or by telephone at (919) 326-1100.

Contact Information

Medical Practice:  Frank J. Welch, MD PLLC

Platform / Management:  Pirate Alley, LLC d/b/a Oak Health Institute

Email:  info@oakhealthinstitute.com

Pharmacy:  Formulation Compounding Center — info@formulationrx.com  |  (469) 946-6690  |  Fax: (469) 946-6691