CONSENT FORM

I authorize GP2ndopinion and any other healthcare person or entity to release any information pertaining to my health including medical history, pathology, laboratory and diagnostic results to my treating doctors. GP2ndopinion is authorized, at its election, to obtain any of such records and information. However, I understand that there may be a charge for copying and handling my medical records and agree to be solely responsible for such charges.

In addition, I understand and agree that:

• GP2ndopinion's online consult is solely based on the information provided by me and/or my Treating Physician and, in the absence of a physical evaluation, the GP2ndopinion doctor may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of my condition and recommended treatment.

• The GP2ndopinion online consult is very different from a regular face-to-face examination and that the GP2ndopinion doctor providing the consult is limited by the oral and written information and imaging provided by myself and my Treating Physician. Accordingly, the diagnosis I will receive is limited and provisional.

• An online consult is not intended to replace a full medical face-to-face evaluation by a physician.

• I will not have direct contact with the GP2ndopinion doctor rendering the opinion unless I decide to travel to GP2ndopinion for an evaluation afterward. The GP2ndopinion doctor's opinion and conclusions, if needed, will be communicated directly to my Treating Physician so that an informed decision can be made in managing my medical needs. My Treating Physician will be responsible for communicating the GP2ndopinion's doctors' opinions and conclusions to me.

• GP2ndopinion and the GP2ndopinion doctor is only rendering an online consult and does not assume any responsibility for my continued medical care or treatment. I understand that my Treating Physician will remain responsible for my treatment.

• I am responsible for all the expenses related to my online consult request including, but not limited to, GP2ndopinion fees, medical report translation fees, and material shipment fees.

• My medical information will be handled with strict confidentiality, privacy, and security;

however, I understand there are risks associated with any electronic transfer process from one location to another.

• I have read, noted and understand GP2ndopinion's terms and conditions on the website.

• I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.

Disclaimer and Release

I hereby completely and irrevocably release GP2ndopinion and its parent and sister corporations and their respective medical staff members, physicians and other health care professionals, insurance providers, administrators, officers, employees and directors (collectively, the "GP2ndopinion") of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the online second opinion consult, conclusions or recommendations provided by GP2ndopinion or its physicians. Furthermore, I agree that GP2ndopinion takes no liability or responsibility for the accuracy or completeness of the medical information submitted to them in any form, oral or written, or for any errors in its electronic transmission.

As a condition to receiving the online consult service, I have read and acknowledged that I have given this consent of my own free will.

By accepting and agreeing to these terms, I acknowledge and agree to assume all the risks of the limitations set forth herein.