Telehealth Consent

1What telehealth is

Telehealth is healthcare delivered through electronic communications instead of an in-person visit. Your care may include:

• Asynchronous ("store-and-forward") review, where a Provider reviews your assessment answers, photos, ID, and records and responds by secure message;
• Live video or phone visits, when required by your state, your treatment, or your Provider's judgment; and
• Secure messaging for follow-up, side effects, and dose adjustments.

2Who provides your care

Your care is provided by independent physicians, nurse practitioners, physician assistants, and other licensed clinicians ("Providers") employed by or contracted with independent medical groups and provider networks (each a "Medical Group"). As of the date above, your Medical Group is [TO CONFIRM: medical group name]. Your Provider's name and credentials are shown in your account. Prescriptions are filled by independent, state-licensed pharmacies named on your label.

Your Provider will be licensed in the state where you are located at the time of your visit. You may ask for your Provider's name, credentials, and license information at any time, and you may ask to see a different Provider when one is available.

3Benefits of telehealth

• Access to licensed Providers without travel or waiting rooms;
• Faster evaluation and follow-up for many conditions;
• Convenient, private communication with your care team.

4Risks and limitations

Telehealth has risks and limits compared with in-person care. By consenting, you understand that:

• No physical exam. Your Provider cannot examine you in person, listen to your heart, or perform in-office tests. Decisions rely heavily on the information you provide. Incomplete or inaccurate information may lead to errors in judgment, a missed diagnosis, or harmful treatment.
• In-person care may be needed. Your Provider may decide telehealth is not appropriate and refer you to in-person care, labs, or a specialist. Telehealth does not replace your primary care provider; we encourage you to keep one and share your treatment with them.
• Technology problems. Poor connections, low image quality, or system failures may delay or interrupt care.
• Security. Despite reasonable safeguards, electronic communications carry a risk of unauthorized access.
• Response times. Messages are not monitored 24/7. Responses typically arrive within one business day but may take longer.
• No guarantee. There is no guarantee you will be prescribed any medication or that treatment will achieve any particular result.

5Prescriptions and pharmacies

• Your Provider decides whether to prescribe, which medication, and the dose, using their independent judgment. They may decline, adjust, pause, or stop treatment.
• Prescriptions may be sent to an independent Partner Pharmacy that ships to you. You have the right to ask that your prescription be sent to a pharmacy of your choice, where the medication and state law allow.
• Compounded medications are not FDA-approved. The FDA does not verify their safety, effectiveness, or quality before they are dispensed. Your Provider will prescribe a compounded medication only when they determine it is clinically appropriate for you.
• Some medications may be prescribed off-label, meaning for a use or dose not on the FDA-approved label. Your Provider will explain this.
• Some medications, including testosterone and phentermine, are controlled substances. They are prescribed only as federal and state law permit, which may require a live video visit, lab work, identity verification, and checks of state prescription monitoring databases.

6Program-specific risks

The medications below are examples of what Providers may prescribe in each program. Your Provider decides what, if anything, is right for you, and will review the risks, side effects, and alternatives for anything prescribed. The dispensing pharmacy will provide full medication information.

Weight Loss

Examples: GLP-1 medications such as semaglutide or tirzepatide; other options may include phentermine, naltrexone-bupropion, topiramate, or metformin.

• GLP-1 medications: common side effects include nausea, vomiting, diarrhea, constipation, and abdominal pain. Serious risks may include pancreatitis, gallbladder disease, kidney injury from dehydration, and low blood sugar (especially with insulin or sulfonylureas). Tell any surgeon or anesthesiologist that you take a GLP-1 medication. Tirzepatide may make birth control pills less effective; use a non-oral or backup method as your Provider directs. Rare sudden vision loss (NAION) and worsening diabetic eye disease have been reported with semaglutide. GLP-1 medications caused thyroid C-cell tumors in rodents; it is unknown whether they do in humans. Report a lump in your neck, trouble swallowing, or persistent hoarseness.
• Compounded GLP-1 medications are not generic versions of, and are not the same as, Wegovy, Ozempic, Mounjaro, or Zepbound. Dosing errors with compounded vials measured in units have caused hospitalizations; measure each dose exactly as instructed and ask your pharmacy if you are unsure.
• Phentermine is a controlled substance. It can raise heart rate and blood pressure and cause insomnia. It is not for people who are pregnant, have heart disease, uncontrolled high blood pressure, hyperthyroidism, or glaucoma, have used an MAOI within 14 days, or have a history of drug misuse.
• Topiramate can cause birth defects, including cleft lip and palate; use effective birth control while taking it. It may also cause tingling, trouble finding words, kidney stones, and sudden eye pain or vision changes (acute glaucoma), which need emergency care.
• Naltrexone-bupropion can raise the risk of seizures and carries a warning about suicidal thoughts. It must not be taken with opioids.

Men's Hormone

Examples: testosterone (injection or cream); your Provider may also consider enclomiphene, hCG, or anastrozole. Testosterone is a controlled substance and requires baseline and ongoing lab work.

• Risks may include a high red blood cell count (which can raise clot risk), higher blood pressure, acne, fluid retention, breast tenderness or enlargement, and worsening sleep apnea or urinary symptoms.
• Testosterone lowers sperm production and can cause infertility and testicular shrinkage. Tell your Provider if you want to have children.
• Testosterone is not for men with breast cancer or known or suspected prostate cancer.
• Enclomiphene is not FDA-approved and may cause mood changes, hot flashes, or vision changes. hCG is dispensed only as an FDA-approved product and may cause headache, mood changes, and breast tenderness. Anastrozole is used off-label in men and can cause joint pain and bone loss if estrogen falls too low.

Men's Vitality

Examples: sildenafil or tadalafil for erectile dysfunction.

• Side effects may include headache, flushing, nasal congestion, indigestion, and back pain.
• Seek emergency care for an erection lasting more than 4 hours, sudden vision or hearing loss, or chest pain during sex.
• Tell your Provider about heart disease, low blood pressure, and any alpha-blockers (for example, for prostate symptoms).

Women's Hormone

Examples: estradiol, progesterone, and in some cases low-dose testosterone, for perimenopause and menopause symptoms.

• Estrogen: if you have a uterus, estrogen without a progestogen raises the risk of endometrial cancer. Estrogen therapy may also increase the risk of blood clots, stroke, heart attack, gallbladder disease, and breast cancer, depending on your age, health history, and the type of therapy. Report any unexpected vaginal bleeding.
• Progesterone can cause drowsiness and dizziness and is usually taken at bedtime. Some capsules contain peanut oil; tell your Provider about a peanut allergy.
• Testosterone for women is off-label in the U.S. It may cause acne, unwanted hair growth, and, at higher levels, voice deepening that may be permanent.

Cellular Health

Examples: NAD+ (injection, nasal spray, or sublingual), glutathione, and methylene blue.

• These therapies are not FDA-approved for cellular health or anti-aging, and evidence in people is limited or still developing.
• NAD+ injections can cause flushing, nausea, cramping, and chest tightness, especially if injected quickly. Glutathione can cause allergic reactions and, when inhaled, may trigger wheezing in people with asthma. Any injection carries risks of site reactions, infection, and allergic reaction.
• Methylene blue turns urine blue-green and must not be used by people with G6PD deficiency or during pregnancy.

Sleep & Recovery

Examples: non-controlled prescription sleep aids such as trazodone, low-dose doxepin, or hydroxyzine; supplements such as melatonin or magnesium; and recovery therapies your Provider considers appropriate.

• Sleep medications can cause next-day drowsiness, dizziness, and falls. Do not drive or operate machinery until you know how a medication affects you.
• Tell your Provider if you have or may have sleep apnea, which sedating medications can worsen.
• Antidepressant-class medications used for sleep (such as trazodone and doxepin) carry a warning about suicidal thoughts in young adults and can contribute to serotonin syndrome with other serotonergic drugs. Trazodone can rarely cause a prolonged, painful erection that needs emergency care.
• Some peptides marketed for recovery cannot lawfully be compounded. Providers prescribe only products a licensed pharmacy may lawfully dispense.

Longevity Stack

Examples: combinations that may include NAD+, metformin, low-dose rapamycin (sirolimus), low-dose naltrexone, acarbose, and supplements.

• No medication is FDA-approved to slow aging. These medications are prescribed off-label, and evidence for longevity benefits in people is limited. Combining several products raises the chance of side effects and interactions.
• Metformin can cause stomach upset and, with long-term use, low vitamin B12. Rarely it causes lactic acidosis, a serious condition; the risk is higher with kidney disease or heavy drinking, and your Provider may pause it before surgery or imaging with contrast dye.
• Rapamycin suppresses the immune system. It can increase infection risk, cause mouth sores, raise cholesterol and blood sugar, and slow wound healing. Tell any surgeon you take it, avoid live vaccines, and avoid grapefruit.
• Low-dose naltrexone can cause vivid dreams, trouble sleeping, and headache.
• Acarbose commonly causes gas, bloating, and diarrhea. If you also take insulin or a sulfonylurea and your blood sugar gets low, treat it with glucose tablets, not table sugar.

Hair Loss

Examples: finasteride or dutasteride, oral or topical minoxidil, and, for women, spironolactone.

• Dutasteride is not FDA-approved for hair loss and is prescribed off-label. Compounded topical finasteride is not FDA-approved, and FDA has received reports of side effects from it. Finasteride and dutasteride may cause lower sex drive, erectile or ejaculation problems, and breast tenderness. Some people report sexual side effects that continue after stopping. Depression and suicidal thoughts have been reported; tell your Provider right away about mood changes. These medications lower PSA test results, so tell any doctor checking your PSA.
• Oral minoxidil is used off-label at low doses. It may cause dizziness, fast heartbeat, swelling, unwanted hair growth, and, rarely, fluid around the heart. Temporary shedding is common in the first months. Topical minoxidil can irritate the scalp and is toxic to cats.
• Spironolactone can raise potassium levels (avoid potassium supplements and salt substitutes unless your Provider approves) and may cause irregular periods, breast tenderness, and dizziness.

7Your responsibilities

You agree to:

• Provide complete, accurate, and truthful information about your identity, medical history, current medications and supplements, allergies, and pregnancy status, and tell your Provider when anything changes;
• Be physically located in an eligible U.S. state during each visit, and tell us if you move;
• Take medications only as prescribed, read the pharmacy information, and never share medication;
• Report side effects promptly through secure messaging, and seek in-person or emergency care when needed; and
• Complete required follow-up check-ins, labs, or video visits before refills are approved.

8Emergencies

9Privacy and records

Your Medical Group protects your health information under HIPAA and applicable state law, as described in its Notice of Privacy Practices and our Privacy Policy. Your information may be shared with Surna (as a business associate), Partner Pharmacies, labs, and others involved in your care, payment, and healthcare operations.

You may request a copy of your medical records at support@surnahealth.com. You may be asked to verify your identity by photo or ID. Please do not record visits without your Provider's permission.

Photos and electronic communication. You consent to sharing photos, ID images, and health information electronically for your care, and to your Provider and pharmacy contacting you by secure message, email, text, phone, or video. Standard email and text messages are not fully secure; you accept that risk for any messages you choose to receive that way.

Automated tools. Surna may use automated tools, including artificial intelligence, for administrative tasks such as organizing your assessment and support messages. Clinical decisions are made only by your licensed Provider. If AI is used to generate messages to you that contain clinical information, you will be told, as required by law, and you can always ask to communicate with a human.

10Financial responsibility

Services are self-pay; we do not bill insurance. You are responsible for fees shown at checkout, including recurring subscription charges described in our Terms of Service.

11Your rights and withdrawing consent

• You may ask questions and get answers about any proposed treatment, including its risks, benefits, and alternatives, before agreeing to it.
• You may decline or stop telehealth care at any time and seek in-person care instead, without affecting your right to future care.
• You may withdraw this consent by messaging your care team or emailing support@surnahealth.com. Withdrawal does not affect care already provided, and you may need to cancel active subscriptions separately.
• You may file a complaint about a Provider with the licensing board for that Provider's profession in your state. Texas residents: complaints about physicians and other licensed health care practitioners may be directed to the Texas Medical Board, 1801 Congress Avenue, Suite 9.200, P.O. Box 2018, Austin, Texas 78768-2018; 1-800-201-9353; www.tmb.state.tx.us.
• This consent stays in effect for all telehealth services from the Medical Group until you withdraw it. If it changes materially, we will ask you to accept the update.

12Acknowledgment and consent

By checking the consent box during your assessment, you confirm that:

• You are at least 18 years old (or the age of majority in your state, if higher) and are located in the state you entered during your assessment.
• You have read and understand this Telehealth Consent, including the risks, limitations, and program-specific information above, and you had the opportunity to ask questions.
• You understand Surna Health is not a medical provider, and that your care is provided by independent licensed Providers and your prescriptions are filled by independent licensed pharmacies.
• You understand compounded medications are not FDA-approved, that some treatments are prescribed off-label or have limited evidence, and that all treatment carries risks, some of which may be unknown. You accept the risks your Provider has explained to you.
• You understand telehealth is not for emergencies, and you will call 911 if you have one.
• You consent to receive, electronically, this consent and related records, and you agree that checking the box is your electronic signature.
• You voluntarily consent to receive care through telehealth.