I understand that I have the right to make informed decisions about my health care treatment. I agree to have the Members of Restoration Health, LLC, its physicians, nurse practitioners, nurses, and any and all other staff (collectively “Medical Providers”) perform tests and treatments they feel are needed for my care. These may include, but are not limited to, vital signs, x-rays and radiological imaging, lab tests, therapies, prescribing medicines, and service utilizing Telehealth and video technology, exclusively or in addition to in-person treatment. I know the potential exists that I may require additional, or other treatments or tests that have more risk and these additional or other treatments or tests will also be explained to me so that I may give informed consent for them if I need them and consent to them. I know I can ask my Medical Providers any questions I may have about my treatment and acknowledge it is my personal responsibility to do so.

I agree to receive text messages and emails from my Medical Providers to a cell phone number and email address I indicate below, acknowledging these methods of communication may not be secure. I understand that data usage and other charges from my cellular provider may apply. If I do not agree to receive text or email messages, I know I can still receive care from Restoration Health, LLC. I understand Telehealth involves a healthcare provider who is at a site remote from my location at the time of service, and, as such, Telehealth often involves the transmission of video, audio, images, and other types of data. Further, I understand that I may have to travel to see a Medical Provider in-person for certain diagnosis and treatment matters. I acknowledge and understand there is no guarantee of diagnosis, treatment, or prescription.

This consent provides Restoration Health, LLC and its Medical Providers with my permission to perform reasonable and necessary medical examinations, testing and prescribe treatment and medication. By signing below, I intend that this consent continues even after a specific diagnosis has been made and treatment recommended. This consent will remain fully effective until it is revoked in writing by me. I acknowledge and understand I have the right to discontinue services at any time by advising my Medical Providers.

I understand prescription medications have risk and potential for side effects, complications, or adverse events. I further understand the Medical Providers of Restoration Health, LLC may utilize the practice of “off label” prescription medication or treatment. I understand “off label” prescribing is the practice of prescribing medication(s) or treatment(s) for reasons other than one of the FDA approved indications.

TO THE EXTENT ALLOWED BY LAW, BY SIGNING BELOW, I RELEASE RESTORATION HEALTH, LLC, ITS MEMBERS, MEDICAL PROVIDERS, AND ALL OTHER PERSONS ASSOCIATED WITH RESORTATION HEALTH, LLC FROM ANY AND ALL LIABILITY FOR ANY AND ALL ADVERSE EVENTS, SIDE EFFECTS, OR UNWANTED OUTCOMES FOR THE PROVISION OF MEDICAL SERVICES, INCLUDING, BUT NOT LIMITED TO, “OFF LABEL” PRESCRIBING PRACTICES.

I certify that I have read and fully understand the above statements and consent to treatment by Restoration Health LLC and its Medical Providers.