• I am over the age of 18. If am under the age of 18 but older than 13, I represent and warrant that my parent or legal guardian authorized to consent on my behalf has read the terms of this Informed Consent to Virtual Care Services (this “Consent”) and accepted them on my behalf.
  

• I am not under the influence of any medications or other substances that could impair my understanding of the information in this Consent. I have had sufficient time to read and understand the information provided in the SimpliFed Terms of Service regarding virtual care. I have had the opportunity to discuss this Consent with my treating Professional providing virtual lactation consulting and baby feeding support services (“Virtual Care Services”) through SimpliFed. I have been given all of the opportunity I require to ask any and all of my questions, and such questions have been answered to my satisfaction in words I understand.
  

• I grant my permission for Virtual Care Services to be performed by SimpliFed’s employed and contracted certified lactation counselors, consultants, nurses, medical doctors, mental health professionals, dietitians, and patient advocates (or Allies) (collectively, my "Care Team") .  I understand that to learn how the Professionals can help me, my Professional may ask about and the Virtual Care Services may consist of the following: a medical history of me and my baby, a virtual, clinical assessment, observation and examination of my breasts and my baby, an assessment of how my baby breastfeeds, the use of breastfeeding aids and equipment, providing helpful hints, recommendations and other educational information to help me reach my breastfeeding goals. I authorize SimpliFed and the Professionals to release the information gained from the Virtual Care Services to my primary care physician(s), health care provider, and insurance company (to assist with claim reimbursement if relevant) unless I specifically object to such release. I understand and agree that the information in this file will be kept for a period that is required by applicable federal and state law.
  
• I acknowledge and accept that all clinical consultations will be conducted via secure video conference accessible via an internet connected mobile phone, tablet, laptop or desktop computer. Virtual Care Services include the use of video, images, telephone consultations, texts, emails, questionnaire, screeners, medical records. I agree to virtual care and understand that no results or outcomes can be guaranteed.
  

• I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. I further agree to work with my clinical care team to help me understand these alternatives to help me make informed decisions.
  

• I acknowledge that, in the exercise of his/her clinical judgment, a Professional may determine: (1) that the nature of my problem is such that it is not professionally appropriate to assist me with that problem through virtual care; or (2) that it may not be lawful for the Professional to diagnose or treat me virtually; or (3) both. In the event that my care team cannot support me virtually, he/she will confer with me about other medical care options such as referring me to my primary care physician.
  

• I will provide my SimpliFed care team with the names and contact information for other relevant healthcare providers for my baby and me. I understand that my care team may communicate with them for the purposes of providing clinical treatment. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for my Professional to send and receive texts and emails that may contain my Personal Health Information (“PHI”).
  

• I understand that it is my choice to have someone else present during a Virtual Care Services session, and that anyone who sits in on the virtual session will have access to my healthcare information and my confidentiality may not be guaranteed. I acknowledge that SimpliFed and/or the Care Team is not responsible for any breach of confidentiality made by any person I invite to be present during a visit.
• I also understand that if I include any anyone else in an email or text with SimpliFed, then I am granting permission for SimpliFed to communicate my health information and that of my baby(ies) with that third party. SimpliFed and/or the Professional will not initiate inclusion of any third party on an email or text. I acknowledge that SimpliFed and/or the Professional is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party.
  

• I understand that I have the right to access and obtain any of my medical records, or recorded during a consult. I can request copies of my medical records.
• I give permission to SimpliFed and/or Care Team to photograph of me and/or my baby(ies) if and only if needed for my health care and treatment. These photos may only be shared with my pediatrician or other healthcare provider that I have provided contact information to SimpliFed. 
• I understand that SimpliFed may share de-identified data with third parties such as research organizations, drug manufacturers, or others. SimpliFed will never share my individually identifiable personal information, including PHI, unless I have provided authorization or as otherwise permitted by law.
• I understand that the laws that protect privacy and the confidentiality of medical information also apply to virtual care, and that no information obtained in receiving virtual care, which identifies me, will be disclosed without my consent. I also acknowledge, however, that the security and privacy of electronic communications cannot be guaranteed.
• I understand that the Care Team  will not prescribe medications.
  

• I understand that, if applicable, I may have to pay SimpliFed in advance through a charge to my credit card or other payment method requested before any Virtual Care Services may be rendered by a Care Team
  

• I have read and understand the Privacy Policy and the Notice of Privacy Practices.
  

• I understand that I have the right to inspect all information obtained and recorded in the course of a virtual care interaction, including any of my medical records, and may receive copies of this information for a reasonable fee.
  

• I understand that I have the right to withhold or withdraw my consent to receive Virtual Care Services at any time, without affecting my right to future care or treatment.
  

• By acknowledging “I AGREE,” I hereby authorize SimpliFed and any Professional performing the Virtual Care Services through the Site or the App to provide care to me virtually in the course of my engagement and treatment, as applicable.
  

• I agree that my electronic agreement to this Consent is equivalent to the signature of a patient. I understand a copy of this Consent is available by printing this document or by request.

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