The purpose of this form is to provide you with information about telehealth and to obtain your informed consent for a telehealth consultation with Goal Mind or another medical practice affiliated with Goal Mind and its affiliates. (collectively “Goal Mind”). If you so consent, a Goal Mind telehealth provider (“Provider”) will use telehealth technology to deliver healthcare services to you. This service is not to be used for urgent or emergency consultations. Nor is it a replacement for primary care services.

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Nature Of Telehealth: Telehealth is the use of electronic information and communication technologies to enable a healthcare provider and a patient at different locations to share medical information, including, for example, for the purpose of evaluation and consultation regarding certain healthcare screening results. The delivery of healthcare via telehealth allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telehealth encounter may include interaction through and with the use of some of the following technologies: synchronous video (e.g. videoconferencing) and/or asynchronous technology, such as store-and-forward technology to exchange medical data and secure messaging portal

communication.