I understand by signing this Health Care Informed Consent (“Consent”), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.

I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care.

I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services.

I understand by signing this Health Care Informed Consent (“Consent”), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.

I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care.

I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services.

I understand by signing this Health Care Informed Consent (“Consent”), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.

I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care.

I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services.

I understand by signing this Health Care Informed Consent (“Consent”), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.

I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms and/or computer networks per the process described below, which will not affect my ability to receive medical care.

I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services.