I understand by checking “Agree” I give my consent to receive in-person or remote, as applicable, healthcare services rendered by a healthcare provider that treats me and is affiliated with West Broadway Medical Services, P.C. (for purposes of this consent only, the aforementioned entity shall be referred to as “the PC”), and who utilizes the Ever/Body, Inc. internet platform (the “Platform”). Care may include, but is not limited to, obtaining a medical history, reviewing a completed patient questionnaire, an in-person or virtual examination, prescribing medication, as appropriate, and providing follow-up treatment, as needed.

I understand that Ever/Body, Inc. provides administrative services to West Broadway Medical Services, P.C., which is independently owned and operated by a licensed physician. Ever/Body, Inc. does not own or operate this entity entities or any other healthcare practice, employ or in any way supervise or control the healthcare providers providing healthcare services and the care provided is the sole responsibility of the independent healthcare practice and its providers I also understand that this healthcare Services Consent Form appears on the Ever/Body, Inc. Platform as a function of the administrative services provided by Ever/Body, Inc. to the PC and this form has been reviewed and approved by the owner of the PC entity listed above.

I understand that using the Ever/Body, Inc. Platform when receiving healthcare services may also include the use of electronic information and communication technologies through which healthcare providers affiliated with the PC will receive my healthcare information for purposes of facilitating an examination. Electronic communication technologies, including audio, video, and/or data communications may be used to transmit data including, but not limited to, personal health information, photographs, videos, prescriptions and medical records between me, the patient, a healthcare provider affiliated with the PC or other healthcare providers as needed.

I understand that the laws that protect privacy and confidentiality of my medical information apply to in-person and remote healthcare services I receive from healthcare providers affiliated with the PC. I also understand that, which the PC strives for best in class privacy protection, it is not currently compliant with the Health Insurance Portability and Accountability Act.

I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury or even death. I understand that there are risks and benefits when receiving in-person or remote healthcare services. I understand that when I receive care, the risks and benefits of such care will be explained to me and I will have the opportunity to ask my healthcare provider affiliated with the PC questions about such risks and benefits.

WARNING! IN THE EVENT OF AN EMERGENCY, CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM. THIS IS NOT AN EMERGENCY SERVICE. Use of the Platform or treatment furnished by healthcare providers affiliated with the PC is for non-emergency use only. Services provided by healthcare providers affiliated with the PC are not intended to replace your primary care medical services.

I hereby acknowledge that there may be risks associated with receiving any type of healthcare services and that I will receive additional information about the risks and benefits of such care at the time services are rendered. I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by healthcare providers affiliated with the PC as a result of use of the Platform or otherwise. As with any other medical services some patients do not respond to prescribed treatment.

I have disclosed all my known health conditions, allergies and medications I am taking, including herbal medications/supplements. I understand that certain treatment options that I may receive from or medications prescribed by healthcare providers affiliated with the PC can be dangerous and may result in medical care that is unnecessary, if I have misrepresented my current healthcare condition and status. I have truthfully answered, both on the Platform, and then in-person or remotely to a healthcare provider affiliated with the PC, all questions related to my current health condition and status prior to receiving treatment.

I authorize the healthcare provider affiliated with the PC to share information pertaining to healthcare services I receive with other individuals for treatment, payment and healthcare operations purposes. I authorize the healthcare provider affiliated with the PC to release information pertaining to my medical treatment to Ever/Body, Inc. and its affiliates.

I understand that the terms herein are contractual and not a mere recital and that I sign/check to agree with this document as my own free act and void of any coercion. The permissions granted herein shall begin on the date I agreed to this document and shall remain effective until terminated by me. I understand that I have the right to withhold or withdraw my consent at any time by submitting a request via email to [email protected].

I understand that clicking “Agree” constitutes a legal signature and verifies that I have read all of the information contained in this Consent Form, I understand the risks and benefits of receiving healthcare services in-person by healthcare providers affiliated with the PC utilizing the Platform, and I have had an opportunity or will have additional opportunities at the time of in-person care, to ask questions of my healthcare provider affiliated with the PC about anything I have not understood up to this point.

Terms and Conditions of Payment

On-going use of the Ever/Body, Inc. internet platform (the “Platform”) and receiving healthcare services in-person from a healthcare provider affiliated with the PC and who utilizes the Platform, constitutes an ongoing agreement to the Terms and Conditions. These terms to which you agree are referred to as “Terms and Conditions” or “Agreement”.

Responsibility for Payment

You understand that Ever/Body, Inc. does not provide healthcare services; however, except as otherwise explicitly stated in this Agreement, Ever/Body will collect payment from you for healthcare provider and pharmacy services you receive. Ever/Body, Inc. will remit all payments received to healthcare providers and pharmacies which render services to you as a result of your utilizing the Platform. Ever/Body, Inc., may charge a fee for healthcare services you may receive as a result of use of the Platform. You agree to make timely payments to Ever/Body, Inc. for all healthcare and pharmacy services that are provided to you. You authorize Ever/Body to remit payment information to the PC and pharmacies that work with the Platform.

You understand by providing your payment information to Ever/Body, Inc., you authorize Ever/Body, Inc. to charge the credit card or other payment method for all items and/or services you receive from the healthcare providers affiliated with the PC and the pharmacies that work with the Platform. Ever/Body, Inc. may use third-party services for the purpose of facilitating payment and the completion of the purchases for healthcare services, rendered in conjunction with use of the Platform, provided by healthcare providers affiliated with the PC. By submitting your payment information, you grant Ever/Body, Inc. the right to provide information to these third parties.

Except as otherwise explicitly agreed between Ever/Body, Inc. and you, you will be billed directly and shall be personally responsible for payment.

Governing Law

This Agreement shall be governed by the laws of the State of New York, without regard to its conflicts of law rules. The parties hereby agree that any and all proceedings related to or arising out of this Agreement shall be maintained in the courts in New York County, New York which courts shall have exclusive jurisdiction for such purpose, and by execution and delivery of this Agreement, each party waives to the fullest extent permitted by law any objection which it may now or hereafter have to the venue of such courts, and further waives any claim that any such action or proceeding brought in any such court has been brought in an inconvenient forum. The parties hereby acknowledge personal jurisdiction for the foregoing purpose. No delay or failure to exercise any remedy or right occurring upon any default shall be construed as a waiver of such remedy or right, or an acquiescence in such default, nor shall it affect any subsequent default of the same or a different nature. The provisions of this Agreement shall be severable, and if any provisions shall be prohibited by law, or invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect. No party hereto shall be considered to be the drafter of this Agreement or any paragraph or term hereof and no presumption shall apply to any party as the “drafter.”

You understand that clicking “Agree” constitutes a legal signature and you are agreeing to the foregoing healthcare Services Consent Form and Terms and Conditions of Payment.

Contact Information

If you have any questions about this Consent, please feel free to contact Ever/Body using one of the following options:

Email: [email protected]

Telephone Number: (212) 653-8724

Mailing Address: Ever/Body, 2159 Broadway New York, NY 10023

Last Update: March 24, 2020