Telehealth Consent

AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION AND CONSENT TO TELEHEALTH
OPEN PAYMENTS NOTICE
Last updated: April 6, 2026

Clinical services available through Locklab are provided by the following independent professional entities (each a “Practice”):

Locklab Provider Group, P.A., a Florida professional services association
Locklab Provider Group CA, P.C., a California professional services corporation
Locklab Provider Group KS, P.A., a Kansas professional services association
Locklab Provider Group NJ, P.C., a New Jersey professional services corporation
US Health and Wellness and other affiliated professional entities that may be formed or engaged in the future (collectively, the “Medical Groups” or “Practices”).

Lock Lab LLC itself does not provide medical care.BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE SERVICE, OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.

AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION

By signing this Authorization, I authorize Lock Lab LLC (“Locklab”), the Practices listed above, US Health and Wellness, and any other affiliated Medical Groups and their respective agents (“Receiving Entities”) to use and disclose my Medical Information, including Protected Health Information, for the following purposes:

Provide me information related to my condition and provide disease management support;
Provide me information about offers and services related to prescription hair loss treatments that may be of interest to me;
Work with partner pharmacies to dispense prescribed medications and manage my treatment plan.

Authorized Recipients:

Locklab’s affiliated pharmacies, agents, and representatives;
Service providers engaged in maintaining or analyzing data for Locklab and the Medical Groups;
My health insurance plans (if applicable).

Medical Information Scope: I understand that my medical information may include my medical history and information relevant to the treatment of hair loss.

Right to Revoke Authorization: I understand that I have the right to revoke this authorization, except to the extent that Locklab, US Health and Wellness, Locklab Provider Group, or any affiliated Medical Group has already used or disclosed my information in reliance on this authorization. To revoke, I must contact Locklab at help@locklab.co.

Re-Disclosure: I understand that if my Medical Information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and may not be protected by applicable privacy laws.

Not Required to Sign: I understand that I may refuse to sign this authorization without affecting my ability to obtain treatment or services provided by Locklab or the Medical Groups.

Copy of Authorization: If I agree to sign this authorization, I will be provided a copy upon request.

Expiration Date: This authorization will remain in effect unless and until I revoke it in writing, except where otherwise required by applicable state law.

INFORMED CONSENT REGARDING USE OF TELEHEALTH

Purpose
This consent form provides you with information about telehealth and obtains your informed consent to the use of telehealth in the delivery of healthcare services by physicians, physician assistants, or nurse practitioners (“Providers”) affiliated with the Practices and Medical Groups, using the online platforms owned and operated by Lock Lab LLC and branded to patients as Locklab (the “Service”). The purpose of this Telemedicine Informed Consent is to ensure that you are fully informed about the procedures, benefits, risks, and alternatives associated with the evaluation and treatment provided by the Practice, and to obtain your voluntary agreement to proceed with such evaluation and treatment.

Use of Telehealth
Telehealth (also called telemedicine) involves the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, using electronic communications when you and your healthcare practitioner are not in the same physical location. It may be used for evaluation, prescribing oral medications, follow-up, and/or patient education, and may include transmission of medical records, photos, personal health information, or live audio/video consultations.

Affiliated Provider Groups
You understand and agree that your medical care through Locklab may be provided by one or more of the Practices or other affiliated Medical Groups and their licensed clinicians (physicians, nurse practitioners, or physician assistants). These groups may include the entities listed above as well as other entities that may be formed or engaged in the future to ensure you receive care from providers licensed in your state. By agreeing to this consent, you consent to receive telehealth services from any current or future affiliated Medical Group working with Locklab. All such providers are subject to the same professional, legal, and regulatory standards of care.

Benefits of Using Telemedicine

Easier and more efficient access to prescription treatment for hair loss.
Access to medical care from anywhere with an internet connection, including the comfort of your home.
Ability to obtain services at more convenient times.
Reduced need for in-office visits.
No risk of exposure to illness in waiting rooms and no need to wait several days for an in-person appointment.

Potential Risks
As with any medical treatment, there are potential risks associated with the use of telemedicine. These risks may include, without limitation, the following:

Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor video and data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur. If you need assistance in the event of a telemedicine equipment failure, please contact us at: help@locklab.co.
Security protocols could fail, causing a breach of privacy of personal medical information.
Because Practice does not have access to your complete medical records, if you do not disclose to your Provider a full list of your medical history, including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions, or allergic reactions, or other negative outcomes may occur.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE PROVIDER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR A TELEMEDICINE ENCOUNTER VIA THE SERVICE.

Emergency Situations
Telemedicine services are NOT emergency services, and your personal data WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

Data Privacy
The Service incorporates security protocols to protect privacy. However, no system is entirely secure. Electronic communications may be susceptible to unintended disclosure. Personal information will not be shared with third parties without your consent, except as required by law.

Open Payments Notice
The federal Physician Payments Sunshine Act requires information about certain payments from manufacturers to physicians and teaching hospitals to be made publicly available. This can be viewed at https://openpaymentsdata.cms.gov.

Your Rights and AcknowledgementsYou acknowledge that:

You have been informed of the potential risks and benefits and have had the opportunity to ask questions and seek clarification, including about alternative treatments.
No guarantees can be made regarding the outcome of any evaluation or treatment.
You may refuse a telehealth visit or withdraw consent at any time by emailing help@locklab.co without affecting your right to future care or losing any benefits to which you would otherwise be entitled.
There are no additional or hidden fees associated with the use of telemedicine.
You have the same privacy rights via telemedicine that you would have during an in-person visit. Your healthcare information may be shared in accordance with the Lock Lab, LLC Privacy Policy and applicable laws. You have the right to request disclosure to third parties via signed written authorization.
Identifiable images or information from the visit will not be shared with researchers or other entities without your express written consent.
You will provide your accurate physical location when asked (or it may be collected via the platform) so the Provider can confirm they are licensed to treat you.
Your telemedicine visit may be with a non-physician provider. You may request that your visit be scheduled with a physician instead.
All information submitted will be part of your medical record. You have the right to review and receive copies of your medical records in accordance with applicable law. Contact help@locklab.co for assistance.
You consent to the disclosure of any medical records prepared by the Practice to your primary care provider (if applicable).
You understand that dissemination of any identifiable images or information will not occur without your express written consent.

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YOUR ACKNOWLEDGMENTS

By clicking “I Agree,” you consent to:

Receive healthcare via telehealth through the Practices and affiliated Medical Groups.
Acknowledge that you may be treated by non-physician providers such as nurse practitioners or physician assistants (and may request a physician).
Accept that telehealth does not guarantee cure or improvement of your condition.
Understand that your Provider may determine telehealth is not appropriate for your condition.
Acknowledge that no sessions will be recorded.
Provide truthful and complete information to Locklab, the Medical Groups, and your Provider(s).
Understand that Locklab partners with pharmacies to fulfill prescriptions.
Accept financial responsibility for the costs of services and prescriptions, which may not be eligible for insurance reimbursement.

STATE-SPECIFIC NOTICES

California: Physicians and midwives are licensed and regulated by the Medical Board of California. To confirm a license or file a complaint, visit www.mbc.ca.gov or call (800) 633-2322.

The California Board of Behavioral Sciences handles complaints regarding marriage and family therapists, licensed educational psychologists, clinical social workers, and professional counselors. Visit www.bbs.ca.gov or call (916) 574-7830.