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I understand that my Provider has elected to utilize telehealth and online communication services to conduct virtual examinations and manage my care plan. This may include 1) electronic consents and questionnaires delivered to my secure Patient Portal and required to be completed prior to my appointment 2) email communications regarding my appointment and login information, and 4) participating in my exam via two-way, live-streamed, video consultations for new and existing patients via a HIPAA-compliant portal.

Authorization to Evaluate Patient via Telehealth

I hereby consent to communicate by cell, e-mail, and online with my Provider so as to arrange and conduct virtual consultations, telemedicine/telehealth, and any other purposes deemed by my provider to be appropriate while I am receiving medical and aesthetic services.

As announced by the US Department of Health & Human Services (“HHS”) on March 17, 2020, I understand my Provider is now authorized to use non-public facing audio and/or video communication technology to provide telehealth, whether or not related to COVID-19, on an acceptable non-public facing platform. I accept that even authorized non-public facing third-party applications potentially introduce privacy risks, but my provider will enable all available encryption and privacy modes when using these applications.

Right to Withdraw Consent

I understand that I have the right to revoke this authorization in writing at any time, but if I do so it will have no effect on any actions taken prior to my revocation. Unless and until I revoke this authorization, it will exist in perpetuity from the date written below. I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from my Provider.

I release and discharge my Provider, the telehealth software portal and all parties acting under my Provider's license and authority from any telehealth medical privacy claims I might otherwise have had prior to HHS’s March 17, 2020 notification. I certify that I have read this Authorization and Release and fully understand its terms.

I have read the above Authorization & Release and consent to the use of Telehealth services.

Due to the extremely high price of medical malpractice insurance, I have elected, as permitted under Florida law, to go without medical malpractice insurance meaning there will be no insurance money to compensate patients who sue me or my affiliated companies for medical malpractice. You have already received notice of my election under the statute not to carry insurance, which is also posted in my office.

AGREEMENT, WAIVER AND FORBEARANCE
I, the patient whose signature appears below, in consideration of Dr. Glenn Charles DO accepting and/or continuing to see me as a patient, and by signing this document, elect to become or continue as a patient of Glenn G. Charles, D.O. and/or any corporation with which he is affiliated, including but not limited to Charles Medical Group, Optimal Wellness Group, LLC., with the full understanding that neither he nor his affiliated companies maintain, provide, hold, purchase, or carry malpractice insurance.

I further agree to hold Dr. Glenn Charles, his staff, trusts, and any affiliated companies harmless from any and all actions arising out of alleged negligence in the rendering of, or the failure to render, medical care or services and hereby waive my right to bring any cause of action based on the rendering of or the failure to render medical care or services and waive any damages resulting or alleged to result from the treatment or failure to render medical care, treatment or services to me by Dr. Glenn Charles, his staff, trusts and/or affiliated companies.

I further agree to pay any and all monetary damages incurred by Dr. Glenn Charles, his staff, trusts, and affiliated companies if I change my mind and violate or attempt to violate this agreement, to include but are not limited to: any and all attorney fees, court costs, and judgments rendered by the courts on my behalf, including both my attorneys fees and costs as well as the fees and costs incurred by Dr. Charles and/or his affiliates in defending any such action.
I hereby agree that should I change my mind and sue in violation of this agreement, that I waive my right to a jury trial and agree that a Judge shall hear the case without prior mediation or arbitration. I also agree that should I change my mind and sue in violation of this agreement, and should Dr. Glenn Charles and/or his affiliated entity prevail, both me and my attorneys shall be jointly responsible for defense costs and attorneys fees.
Should any part of this agreement be held invalid, it shall not invalidate any other part of this agreement.

Use and Disclosure of your Protected Health Information

Your Protected Health Information will be used by Optimal Wellness Group , LLC or may be disclosed to others for the purposes of treatment, obtaining payment, or

supporting the day-to-day health care operations of this office.

Notice of Privacy Practices

You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. You may review the notice prior to signing this consent. You may request a copy of the Notice at the Front Desk.

Requesting a Restriction on the Use or Disclosure of Your Information -You may request a restriction on the use of your Protected Health Information.

-This office may or may not agree to restrict the use or disclosure of your

Protected Health Information.

-If we agree to your request, the restriction will be binding with this office. Use of disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Revocation of Consent

You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Florida law requires that physicians who do not carry malpractice insurance to give their patients the following statement to read and sign; the signed form must be kept on the patient's chart. Thus, kindly read this statement, sign it, and date it. We will be happy to provide you with a copy, if you wish.

"Under Florida Law, physicians are generally required to carry malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice.

YOUR DOCTOR GLENN CHARLES, D.M.O AND OPTIMAL WELLNESS GROUP, LLC HAS DECIDED NOT TO CARRY MEDICAL MALPRATICE INSURANCE.

This is permitted under Florida Law subject to certain conditions. Florida Law imposes penalties against uninsured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law. Fla.Stat. 458.320(5)(g)