TELEHEALTH CONSENT FORM

I understand that Immune Co. a/k/a MoldCo (“MoldCo”, “we”, “us”, or “our”), a technology company which provides administrative services through its online platform to facilitate connecting me (“patient”, “me”, “you” or “your”) with me third party lab testing providers (each, a “Third Party Lab”) for lab testing and related services, in connection with mold and biotoxin related health care conditions.  I understand that MoldCo and Third Party Lab may engage in consultation, transfer of  personal and health information, emails, telephone conversations and education using interactive audio, video data communications and the use of output data from medical devices, sound and video files (“Telehealth”). I understand that Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means, at times asynchronously, between a healthcare provider and a patient who are not in the same physical location. 

By acknowledging my consent below, I understand and agree to the following:

1. I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties.  I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.
2. I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with Third Party Lab.
3. I understand that I will be required to consent to a Third Party Labs’ respective consent to telehealth and notice of privacy practices, and any other terms and conditions governing the Telehealth and any related services with such Third Party Lab. 
4. In the event, I engage with Third Party Lab Junction f/k/a Vital Labs (“Junction”) for lab testing or related services, I understand that I will receive Telehealth through affiliated practices of Junction which includes, as applicable, Openloop Healthcare Partners, PC, Openloop Healthcare Partners California, PC, Openloop Healthcare Partners Colorado, PC, Openloop Healthcare Partners New Jersey, PC, Openloop Healthcare Partners Wisconsin SC, Reliant.MD Medical Associates, PLLC, Reliant.MD Medical Associates California, PC, Reliant.MD Medical Associates Colorado, PC, Reliant.MD Medical Associates New Jersey, PC, Reliant.MD Medical Associates Wisconsin, SC, MECNB Physician Services, PC, MECNB Physician Services California, PC, MECNB Physician Services Colorado, PC, MECNB Physician Services New Jersey, PC, and MECNB Physician Services, SC.  I understand that Junction will administer and coordinate the ordering and scheduling of my lab test, and I understand that I will be required to consent to Junction’s separate consent to telehealth and notice of privacy practices, and any other terms and conditions applicable to the Telehealth services provided by Junction.
5. To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.
6. I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.
7. In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.

CONSENT FOR GENETIC TESTING

• If genetic testing is being ordered by any of MoldCo’s network of physicians and provider practices (each, a “Provider”), I acknowledge that I have requested the performance of the genetic test (“Genetic Test”) at the Third Party Lab designated and ordered by the Provider. I acknowledge that my submission of a DNA specimen to be tested is voluntary.
• I understand that the purpose of the Genetic Test is to look for mutations or genetic characteristics known to be associated with certain genetic diseases, conditions, or pharmaceutical therapies related to mold or biotoxin exposure. I acknowledge that I have reviewed information specific to the Genetic Test and understand the Genetic Test’s risks, benefits, and limitations.
• I acknowledge that I have been provided with information about obtaining genetic counseling prior to giving my consent, and I understand that I may seek consultation with a geneticist, genetic counselor, and/or physician after testing.
• I understand that I will be asked to provide a blood, cheek swab, or saliva specimen in accordance with specified collection procedures.
• I understand that my specimen, along with my other personal and health information, will be sent for analysis to the Third Party Lab. DNA will be extracted from the specimen, and certain markers within regions of my genome relevant to the Genetic Test will be sequenced and analyzed. Upon successful completion of the Genetic Test, the results will be sent to me or my authorized representative. No other tests will be performed using the specimen except as authorized herein or permitted by applicable law.
• I hereby acknowledge that the Genetic Test results may become part of my permanent medical record and understand that some test results may impact my ability to obtain certain insurance benefits or insurance pricing. Laws against genetic discrimination may not apply to the military. I hereby acknowledge that genetic test results may have implications for my biological family members and unexpected family relationships may be identified through genomic testing.
• I acknowledge that the Genetic Test analyzes specific gene regions based on currently available information in the medical literature and scientific databases, as well as lab informatics and algorithms that may be subject to change. I further acknowledge that, as such, new information may replace or add to the information that was used to analyze my results that may impact the interpretation of results. I hereby acknowledge that, as with any lab test, there is a possibility of error including a false positive or a false negative result. Other sources of error, while rare, include specimen mix-up, poor specimen quality or contamination, inherent DNA sequence properties, and technical errors in the Third Party Lab.
• A positive Genetic Test result is indication that I may be predisposed to or have the specific disease or condition tested for.  I may wish to consider further independent testing and/or to consult a physician or genetic counselor.  I understand that a negative result does not guaranty that I will not develop the disease or condition tested.
• I acknowledge that if I have certain rare biological conditions or have had certain bone marrow, kidney, liver or heart transplants, transfusions, or hematologic malignancies, these conditions may limit the accuracy or relevance of the results or prevent the Genetic Test from being completed.
• I hereby acknowledge that MoldCo, Provider, and Third Party Lab each expressly disclaim any liability for the inaccuracy of the genetic test results due to such conditions or the failure to provide accurate, correct or complete information.
• I acknowledge that Provider and Third Party Lab will obtain, retain, or use my personal, genetic and health information, specimen, and test information in compliance with applicable law and maintain the confidentiality thereof and protect from unauthorized disclosure or misuse in accordance applicable legal requirements. To the extent permitted by law, Provider and Third Party Lab may de-identify my discarded specimen and information for regulatory compliance purposes, internal quality control, validation studies, or research and development. I understand that any use or disclosure of the specimen and any data will be done in an anonymized manner by either encrypting or removing personally identifiable information in accordance with applicable law. 
• I give my DNA sample to the applicable Third Party Lab and it may be discarded or retained by the Third Party Lab as they deem appropriate and in accordance with applicable state and federal law. I understand that some samples may be stored indefinitely for test validation or education purposes after personal identifiers are removed. I agree that I am giving up any property or other interest in the DNA sample. As applicable, I understand that in certain states I have the option of giving Third Party Lab permission to store any specimen that remains after testing has been completed. All New York samples are discarded 60 days following test completion. I understand that I may request disposal of my sample by contacting Provider or Third Party Lab.
• The Third Party Lab results will be maintained in my records for as long as the applicable Provider and/or Third Party Lab elects to retain them.
• None of MoldCo, my Provider, nor the Third Party Labs will use my information to grant or deny any insurance, employment, mortgage, loan, credit, public accommodation, educational opportunity or any other use prohibited by applicable law. The following are some of the examples of how my DNA analysis, genetic test results and other information and samples may be used and shared with others, as allowed by law: (i) with other healthcare providers and entities for treatment; (ii) with health plans and other payers as needed for payment for my testing and treatment; and (iii) for a Provider’s and Third Party Lab’s health care operations, including quality assurance and other lawful purposes.

By acknowledging below, I certify:

• that I have read this form and/or had it explained to me
• that I understand the risks and benefits of a Telehealth appointment
• That I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.