Group Telehealth Informed Consent

Welcome to Social Impact Technologies, Inc. (Swap Health)

I understand that my health and wellness provider Social Impact Technologies, Inc. (Swap Health) wishes me to

participate in a group Telehealth session.

This means that through an interactive video connection, I will be able to see, listen to, and/or speak with the above named provider

alongside other people who may be present in the session.

I understand there are potential risks with this technology:

The video connection may not work or it may stop working during the consultation.

The video picture or information transmitted may not be clear enough to be useful for the consultation.

Benefits of a telehealth session are:

I do not need to travel to a physical location.

I have access to a specialist through this technology.

I also understand other individuals may need to use the Swap Health Telehealth platform and that they will take reasonable steps to maintain confidentiality of the information obtained. I have read this document and understand the risk and benefits of the Telehealth consultation and have had my questions regarding the procedure explained and I hereby consent to participate in Telehealth sessions under the Conditions described in this document.

Confidentiality

Anything said between any two or more group members at any time is part of the group and is confidential.

I understand that everything said in this group is confidential and not to be shared with anyone outside of the group, except as may be otherwise required by law.

I agree to keep confidential the names of other members of the group and what is said in the group. As a member of this group, I agree to not disclose to anyone outside the group any information that may identify another group member. This includes, but is not limited to, names, physical descriptions, biological information, and specifics to the content of interactions with other group members.

I agree to indemnify and hold Social Impact Technologies, Inc. (Swap Health) harmless for any loss or damages, including costs and attorney’s fees, incurred by Social Impact Technologies, Inc. (Swap Health) as a result of my breach of another’s

confidentiality. Confidentiality of audio and video communications in individual and group nutrition counseling sessions are

protected by encryption and on a secure site. By reserving a spot in Swap Health’s virtual cook-along classes I agree that I

read, understand, and accept the information and conditions specified in this agreement.