It may become useful during the course of treatment to communicate by email, text, or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with VIP Ketamine Clinics and its staff, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:

• People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages;

• Your employer, if you use your work email to communicate with me;

• Third parties on the Internet such as server administrators and others who monitor Internet traffic.

If you are concerned about methods of communication that are more secured, please talk with VIP Ketamine Clinics staff about ways to keep your communications safe and confidential. If you are willing to communicate electronically, with the understanding that it is unsecured and that your information may be accessed or intercepted by others, please proceed with signing the consent below.

CONSENT FOR TRANSMISSION OF PROTECTED INFORMATION BY NON-SECURE MEANS

I consent to allow VIP Ketamine Clinics and its staff to use unsecured email, text, or other means of unsecured electronic communication to transmit to me the following protected health information: