AUTHORIZATION AND CONSENT TO PARTICIPATE IN REMOTE HEALTH SERVICES

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Last Updated: December 30, 2025. This consent applies to all telehealth evaluations conducted through Oak Longevity, RetaClinic, Mito Health Holdings Corp. and Flow Longevity.

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The purpose of this form is to obtain your consent to participate in a Remote Health evaluation (the “evaluation”).

1. Purpose and Benefits. The purpose and benefit of the evaluation is to provide more timely and available access to medical services.

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2. Nature of Evaluation. During the evaluation:

Clinician personnel assist with the encounter and any routine or emergent needs which may arise.

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Non-medical technical personnel may be able to monitor the evaluation in order to assist with any potential or actual electronic transmission and/or communication issues, and to ensure quality compliance.

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3. Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this evaluation. Additionally, dissemination of any patient-identifiable images or information from this interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws. Prescriptions are transmitted electronically to Oak's contracted pharmacies via secure, HIPAA-compliant electronic prescribing systems. In rare cases where a wet signature is required by applicable law, additional processing time may apply.

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4. Modality. Remote evaluation based on online questionnaire if/when permitted by state law.

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5. Confidentiality. All existing confidentiality protections under applicable federal and state laws apply to information disclosed during this evaluation, including the laws of the state in which you are located at the time of your evaluation.

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6. Fees. Fees are disclosed to you during you online check out.

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7. Risks and Consequences. The evaluation will be similar to a routine physician office visit, except interactive technology will allow you to communicate with a health professional at a distance and remotely. As with any medical procedure, there are potential risks associated with the use of Remote Health. These risks include, but are not limited to:

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1. In rare cases, the health professional may determine that the transmitted information is of inadequate quality, thus necessitating other options
2. Delays in medical evaluation and treatment could occur.
3. In rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
4. In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

8. Acknowledgments. By authorizing and consenting to Remote Health, you are acknowledging “Informed Consent, and you understand and agree with the following:

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1. The evaluation may involve electronic communication of your personal medical information to other medical practitioners who may be located in other areas, including out of state.
2. You may expect the anticipated benefits from the evaluation, but that no results can be guaranteed or assured.
3. You understand and acknowledge that your telehealth evaluation will be conducted by independent licensed physicians and nurse practitioners contracted through Oak's medical group partners. These providers maintain their own provider-patient relationship with you and operate under their own professional and legal obligations. By consenting to this evaluation, you authorize those providers to evaluate, diagnose, and prescribe treatment as they determine appropriate in their independent clinical judgment.

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9. Rights. Withdrawal of consent after a prescription has been issued and transmitted to a pharmacy will not cancel or reverse that prescription. To cancel a pending prescription, you must contact Oak directly at care@oaklovesyou.com.

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By proceeding, you confirm that you have read and understood the potential risks, consequences, and benefits described in this consent form, and that you have had the opportunity to seek clarification before agreeing.

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Last updated: December 30, 2025

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