Wellesley Medical provides medical services via telehealth, using secure audio and video technology. By signing below, I acknowledge and agree to the following:

— My evaluation and ongoing care may be conducted via telehealth rather than in person.

— Telehealth involves the communication of medical information using electronic means. I understand that the information transmitted may include my medical history, examination findings, lab results, and treatment recommendations.

— I understand that telehealth has potential risks, including technology failures, interruptions, or limitations in the ability to perform a physical examination. In such cases, my provider may recommend an in-person visit.

— I understand that I may decline telehealth services at any time and request an alternative form of care.

— I understand that my telehealth visit will not be recorded.

I voluntarily consent to medical evaluation, treatment, and services provided by Seth Lampert, MD and Wellesley Medical. I understand that medicine is not an exact science and that no guarantees have been made to me regarding the outcome of any evaluation, treatment, or procedure. I understand that I have the right to ask questions about any proposed treatment and to refuse any treatment at any time.