Telehealth Consent

AUTHORIZATION TO USE AND DISCLOSE MY MEDICAL INFORMATION AND CONSENT TO TELEHEALTH
OPEN PAYMENTS NOTICE
Last updated: May 18, 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; or
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. Lock Lab, LLC ("Locklab") is a management services organization. Locklab provides administrative, technology, payment processing, and other non-clinical support services for the Medical Groups and their Providers. Locklab does not employ, supervise, or direct any Provider in the exercise of clinical judgment. All clinical decisions, including whether to prescribe, what to prescribe, and whether telehealth is appropriate for your condition, are made solely by your Provider in their independent professional judgment. 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.

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 medical history, health intake questionnaire responses, photographs submitted for evaluation, current and past medications and supplements, allergy information, demographic and lifestyle information, and any other information relevant to my clinical evaluation and the treatment of hair loss or related conditions.

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.

The Providers available through the Service are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your primary care provider, if you have one, and we encourage you to establish one if you do not. The Medical Groups do not operate in-person clinic locations. Accordingly, some clinical needs may not be appropriate for a telehealth visit, and your Provider will make that determination in their professional judgment. Your Provider may determine that your condition requires an in-person evaluation, laboratory testing, or referral to a specialist, in which case you will be directed accordingly.

Electronic Transmissions

The types of electronic transmissions that may occur using the Service include, but are not limited to:

Appointment scheduling, reminders, and notifications;
Completion, exchange, and review of medical intake forms, health questionnaires, photographs, and other clinically relevant information between you and your Provider via asynchronous (store-and-forward) communications;
Two-way interactive audio communication;
Two-way interactive audio and video communication;
Delivery of consultation reports, prescriptions, or treatment plans; and
Other electronic transmissions for the purpose of rendering clinical care to you.

Your Provider will determine which transmission method is clinically appropriate for your consultation.

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 Acknowledgements. By clicking “I Agree,” You 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, and accept that telehealth does not guarantee cure or improvement of your condition.
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 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.
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. You may also request to have copies sent to another designated healthcare provider. 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 agree to receive healthcare via telehealth through the Practices and affiliated Medical Groups, which may include non-physician providers such as nurse practitioners or physician assistants. You may request a physician instead.
Understand that your Provider may determine telehealth is not appropriate for your condition.
Acknowledge that no sessions will be recorded.
Agree to provide truthful and complete information to Locklab, the Medical Groups, and your Provider(s).
Understand that Locklab partners with pharmacies to fulfill prescriptions, and you have the right to fill any prescription at the pharmacy of your choice upon request.
Accept financial responsibility for the costs of services and prescriptions, which may not be eligible for insurance reimbursement.

Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

California: Physicians and midwives are regulated by the Medical Board of California. To confirm a license or file a complaint, go here or call (800) 633-2322.

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Maine Board of Osteopathic Licensure’s website, here.

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Oklahoma Board of Osteopathic Examiners’ website, here.

Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Texas: I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us

Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here

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