Effective Date: November 16th, 2025

By clicking “I Agree,” checking a box, using the TakeBack Health, LLC (“TakeBack Health”) platform, or otherwise affirmatively accepting this Consent, you confirm that you have read, understood, and agreed to the terms below.

1. Purpose

This Telehealth Consent (“Consent”) is intended to inform you of the nature of telehealth services and to obtain your voluntary agreement to receive healthcare services via telehealth from independent licensed healthcare providers (“Providers”) affiliated with a professional medical entity (the “Medical Group”) accessible through the TakeBack Health platform (“Platform”).

TakeBack Health is a Management Services Organization (MSO) and technology platform. It does not provide medical care.

2. Use of Telehealth

Telehealth involves the use of secure electronic communication technologies to facilitate diagnosis, consultation, treatment, education, care management, and self-management between you and a Provider who is not in the same physical location. This may include:

• Transmission of medical records, photos, video, or health data
  
  
• Real-time video or audio interactions
  
  
• Use of secure messaging and patient portals
  
  

You understand that:

• You may choose in-person care as an alternative at any time
  
  
• Not all conditions are appropriate for telehealth evaluation or treatment
  
  

3. Risks of Telehealth

While telehealth can improve access to care, you acknowledge potential risks, including but not limited to:

• Limitations in the Provider’s ability to examine you physically
  
  
• Technical interruptions or communication errors
  
  
• Delays in care due to technology or provider availability
  
  
• Inaccurate transmission of information
  
  
• Data security or privacy breaches despite safeguards
  
  

You further acknowledge that no guarantees can be made regarding treatment outcomes, and your condition may not be cured or may worsen.

4. Emergency Situations

The Platform is not appropriate for emergency or urgent care. If you are experiencing a medical emergency, call 911 or go to the nearest emergency facility.

If you are unable to reach your Provider via the Platform due to a technical issue, contact us at:
[Insert Phone Number]

5. Data Privacy

All Providers and the Medical Group will comply with applicable privacy laws. Information shared during telehealth visits may include personal and health-related information, which may be stored electronically. Providers may disclose your information only for treatment, billing, platform operations, or as otherwise allowed by law. Additional protections may be outlined in the Provider’s Notice of Privacy Practices.

6. Acknowledgments and Consent

By accepting this Consent, you confirm that:

• You voluntarily consent to receive healthcare via telehealth
  
  
• You understand the potential risks, benefits, and limitations of telehealth
  
  
• You may withdraw your consent at any time by providing written notice
  
  
• You are responsible for providing accurate and complete information
  
  
• You understand that Providers may determine that your condition is not appropriate for telehealth and may recommend in-person care
  
  
• You understand that any services, including prescriptions, are provided at the discretion of the Provider
  
  
• You agree to pay for services out-of-pocket and not seek insurance reimbursement
  
  
• You understand that you may use a pharmacy of your choice, although the Platform may partner with specific pharmacies for fulfillment
  
  

If you have questions about this Consent or the services provided, please contact us at:
TakeBack Health, LLC