Liability and Consent Agreement

Social Impact Technologies Inc.

Effective Date January 2nd, 2022

THIS AGREEMENT IS AN IMPORTANT LEGAL DOCUMENT. IT EXPLAINS THE RISKS YOU ARE ASSUMING BY STARTING A NUTRITION PROGRAM. IT IS CRITICAL THAT YOU READ AND UNDERSTAND IT COMPLETELY. UPON SIGNING UP FOR THE SWAP HEALTH APP, YOU ARE AGREEING TO OUR LIABILITY AND CONSENT POLICY.

Nutrition Disclaimer

The nutrition advice given by Swap Health Dietitians “Swap Health/Dietitian In Your Kitchen, LLC”, is based on the information provided by the client/individual. The nutrition information given is meant only for the client/individual signing up for Swap Health’s services. It is the sole responsibility of the client/individual to provide complete and accurate information. Any misinformation or omitted information may affect the nutritional/ assessment and/or advice. Any misrepresented information is solely the client’s/individual’s responsibility and Dietitian In Your Kitchen, LLC DBA Swap Health, will not be liable. Dietitian In Your Kitchen, LLC DBA Swap Health, provides nutrition consulting and recommendations only and is not licensed to diagnose a medical condition or illness. The client/individual must consult a physician for any medical advice.

Waiver and Covenant Not to Sue

I have volunteered to participate in a wellness program and possible follow-ups under the direction of the Swap Health/Dietitians at Dietitian In Your Kitchen, which will include, but may not be limited to nutritional planning. In consideration of the Swap Health/Dietitians at Dietitian In Your Kitchen agreement to assist me, I do here and forever release and discharge and hereby hold harmless the Dietitians at Swap Health/Dietitian In Your Kitchen and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in any nutrition program including any injuries resulting there from.

Assumption of Risk

I recognize that specific foods may create allergic and possible fatal reactions, most specifically, products containing nuts. I have therefore specified any food allergies/ sensitivities I am aware of on the "diet profile" form. I am aware that specific foods may interact with certain medications. I have discussed the side effects of all of my medications with my doctor or pharmacist. I also understand the wellness information I receive will not take my medications into consideration unless I choose to list my medications on the "diet profile" form. If I am pregnant or lactating, have high cholesterol, high blood pressure, high blood sugar, diabetes, renal disease, gastric by-pass surgery or any other medical condition that requires special dietary restrictions, I must receive permission from my physician before participating in the nutrition program, or may be advised to seek help from another health professional.

Consent for Treatment, Payment & Healthcare Operations

I consent to Dietitian In Your Kitchen, LLC DBA Swap Health’s (hereby referred to as the “Practice”) use and disclosure of my Protected Health Information for the purposes of providing treatment to me, for purposes relating to the payment of services rendered to me, and for the Practice’s general healthcare operations purposes. Healthcare operations purposes shall include, but not be limited to, quality assessment activities, credentialing, business management and other general operation activities. I understand that the Practice’s diagnosis or treatment of me may be conditioned upon my consent as evidenced by my signature on this document.

For the purposes of this Consent, “Protected Health Information” means any information, including my demographic information, created or received by the Practice, that related to my past, present or future physical or mental health or condition; the provision of health care to me; and that either identifies me or from which there is a reasonable basis to believe the information can be used to identify me.

I understand I have the right to request a restriction on the use and disclosure of my Protected Health Information for the purposes of treatment, payment or healthcare operations of the Practice, but the Practice is not required to agree to these restrictions. However, if the Practice agrees to a restriction that I request, the restriction is binding on the Practice.

If participating in a group program, I understand participating in a Community Chat is my choice as to what to share to the group. I am under no obligation to participate in chats or share information.

It is the office’s policy to call, text or email patients as a reminder of their next scheduled appointment of if they have missed an appointment.

I understand I have a right to review the Practice’s Notice of Privacy Practices prior to the signing of this document. The Notice of Privacy Practices describes my rights and the Practice’s duties regarding the types of uses and disclosures of my Protected Health Information.

I understand I have the right to request to work with any dietitian in the Swap Health/Dietitian In Your Kitchen practice or request to work with a dietitian outside this practice at any time.

I have the right to revoke this consent, in writing, at any time, except to the extent that the Practice has acted in reliance on this consent.

I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this nutrition program. I understand that results are individual and may vary.

For individual clients: I understand if my insurance company deems the the nutrition initial assessment and nutrition follow up sessions are not medically necessary, these services will be provided based on the dates agreed upon by myself and the dietitian and the cost of the service will not exceed the rate of $160 per hour (billed to insurance).