Consents and Communica tio n Name___________________________________________Date__________________________ Pharmacy Please list your pharmacy, and it’s cross streets: Communica ti on Persons authorized to be included in issues regarding your health: Name_________________________________Rela tio nship_______________Phone__________ Name_________________________________Rela tio nship_______________Phone__________ Telehealth Telehealth involves the delivery of healthcare services using electronic communica tio ns such as phone, tex ti ng, email, and video. Telehealth may be used for diagnosis, treatment, follow-up and/or pa ti ent and educa tio n. The electronic systems used in our Service will incorporate network and s oftware security protocols to protect the privacy and security of health informa ti on, and will include measures to safeguard the data to ensure its integrity. I understand that I am advised to use the c onfid en tia l systems established by Your Wellness MD, but that if I ini ti ate communica ti on with my health care provider through another means I will accept a response with that means of communica ti on. Signature______________________________________________________________________ Privacy Prac ti ces I have read the No ti ce of Privacy Prac tic es provided to me on the website of Your Wellness MD, and I understand that my medical informa ti on is subject to all applicable laws regarding the con fi den tiali ty of healthcare informa ti on. Signature______________________________________________________________________ Membership Agreement I have read and understood the Membership Agreement/Direct Primary Care Pa tie nt Agreement provided to me on the website of Your Wellness MD, have had my ques tio ns answered, and agree to its terms. Signature______________________________________________________________________