WMG Informed Consent

Effective Date: 04/01/2021

I, as the individual (or his or her legal representative) receiving services, agree to receive the
services provided by Wilcrest Medical Group, PA, hereinafter referred to as (“we” “us” or
“Wilcrest”) or its business services provider FPK Services, LLC. I agree that the services may
include health care provider education sessions, physician consultations via telemedicine
(“Consults”), any customer support or counseling, and any other related services provided by
Wilcrest via telemedicine such as ordering laboratory tests (“Tests”), including, without
limitation, physician oversight, for the ordering of Tests, the results of the Tests, the
(“Results”)and any other related services provided by Wilcrest directly or through its business
services provider, FPK Services, LLC, (the “Services”).

I acknowledge and agree to the following:

● I have read, understand, and had the opportunity to ask questions about the information
provided about Wilcrest’s Services.

● My medical history is correct to the best of my knowledge. I will not hold Wilcrest, its
business associates, its business services provider, or its physicians, nurse
practitioners, or employees responsible for any errors or omissions that I may have
made in providing such information.

● (“Health Care Providers”) means Wilcrest, its physicians, nurse practitioners, and

● I authorize Wilcrest and its affiliates, and third-party business services provider FPK
Services, LLC, the owner and operator of STDcheck.com, UTItreatment.com and
Healthlabs.com (“Wilcrest’s Care Coordination Team”), business associates,
professional corporations, Health Care Providers, staff, and agents to view and use my
health information, including any Test Results in furtherance of its healthcare operations.

● Only Wilcrest physicians diagnose conditions, disease, or illness.

● If I receive an abnormal Result on a Test I understand that a member of Wilcrest’s Care
Coordination Team will attempt to call me to review the Results, offer education and
explain the next steps I should take. Wilcrest’s Care Coordination Team may leave me a
voice message at my designated telephone number. I also understand that if I am not
able to be reached, Wilcrest’s Care Coordination Team will mail a follow-up letter to my
designated address (the letter will not include my Test Results). If I receive an abnormal
Result and have not connected with Wilcrest’s Care Coordination Team, I understand
that I should not delay following up with my personal physician.

● I understand that after receiving my Results for an STD Test, including HIV, I will have
the opportunity for a telemedicine Consult. I understand that after receiving my Results
for non-STD Tests, I will have the opportunity for either an education session with a
member of Wilcrest’s Care Coordination Team, a Health Care Provider, or a
telemedicine Consult with a Wilcrest physician, as appropriate under applicable law. If
my Results show that I have Chlamydia, Gonorrhea, Herpes Simplex 2, or
Trichomoniasis (the “Treatment Conditions”), the physician may be able to prescribe
medication during the Consult, if appropriate. I understand that if my Results show that I
have one of the Treatment Conditions, it is important to schedule a Consult as soon as
possible or obtain other treatment.

● I certify that throughout the duration of my Consult I will be physically present in the state
of residence I provided or other state of which I have notified Wilcrest.

● Wilcrest’s Health Care Providers are responsible for sharing information regarding any
Consults and forwarding any Results to my primary care or other personal physician
within 72 hours after providing such Consults or receiving such Results. I am responsible
for initiating follow-up care with my physician. I will let Wilcrest’s Care Coordination
Team know of my desire to have my information forwarded to my primary care or other
personal physician, and I will fill out the required release form.

● I will not make medical decisions without consulting a health care provider or disregard
medical advice from my health care provider or delay seeking such advice based on
information I receive as a result of my Consult.

● If I receive an abnormal Result on certain STD Tests, my name and Result will be
disclosed to my state health agency in accordance with applicable law.

● If I receive an abnormal result on an STD Test, it is important that I notify my sexual and
needle sharing partners and follow up with my personal physician to receive treatment.

● I understand that Wilcrest Consults are delivered by physicians who are not in the same
physical location as I am, using electronic communications, information technology or
other means, including the electronic transmission of personal health information, and
that they may not have the opportunity to perform an in-person examination of me. I also
understand that a physician will determine whether or not treatment is appropriate for
me, based on information I provided.

● For Consults, the scope of Services will be at the sole discretion of the physician treating
me, with no guarantee of diagnosis, treatment, or prescription, and the standard of care
will be the same as it would be if I were receiving such services in-person. The physician
will determine whether or not the condition being diagnosed and/or treated is appropriate
for a telemedicine encounter.

● I have the right to withdraw my consent to use telemedicine in the course of my care at
any time by contacting Wilcrest’s Care Coordination Team by calling 1 (800) 456-2323
or [email protected].

● Any video feed from the Consult will not be retained or recorded by Wilcrest.

● My health and wellness information pertaining to telemedicine services are governed by
Wilcrest’s Notice of Privacy Practices.

● I may need to see a health care provider in person for diagnosis, treatment and care.

● There are potential risks associated with the use of technology that are beyond
Wilcrest’s and any health care provider’s control, including disruptions, loss of data, and
technical difficulties.

● There are alternative services available to me if I experience medical symptoms that
require immediate attention, such as visiting a primary care provider, an emergency
room, or an urgent care facility; however, I voluntarily choose to proceed with Wilcrest’s
Services at this time.

● I have been provided with notice of how I may file a complaint with the Texas Medical
Board relating to the provision of telemedicine services by Wilcrest Health Care
Providers. I understand that I may contact the Texas Medical Board electronically by
submitting an online complaint form at tmb.state.tx.us or print a copy of the complaint
form and mail it in, or call the complaint hotline at 1-800-201-9353.

I understand that if I have any questions before or after my Test, I can contact Wilcrest’s Care
Coordination Team by calling 1 (800) 456-2323 or [email protected].

I authorize Wilcrest to use the email address and phone number I provided in connection with
my account and to contact me in connection with my Consult including follow-up after the
Consult. I am responsible for contacting Wilcrest’s Care Coordination Team by calling 1 (800)
456-2323 or [email protected] to notify them of any changes to my mailing address, email
address, phone number, medical history or other information that I provided in connection with
the Services.

I have read this Informed Consent carefully, and all my questions were answered to my
satisfaction. I hereby consent to receive Services from Wilcrest pursuant to the terms,
conditions, standards, and requirements set forth herein