ACNE FOCUS GROUP INFORMED CONSENT

Last revised July 10th, 2023

General Information

IM Pro Makeup NY LP has engaged Beluga Health, P.A. (“Beluga,” collectively with IM, “IL MAKIAGE®”, “we”, “us”, or “our”) to provide you with medical services for the treatment of acne through Beluga’s network of physicians and health professionals (“Health Professionals”). Our Health Professionals will provide you with a personal treatment plan and assess the progress of your treatment based on a review of your medical history and uploaded photos that you provide us during your participation in the Acne Focus Group. As a member of the Acne Focus Group, you will not be charged for the medical services we provide.

Our physicians or nurse practitioners (“Health Professionals”) will provide you with medical services by reviewing your medical information and providing you with advice or a treatment plan in the form of a written recommendation. Where appropriate, a Health Professional may prescribe medication.

Telehealth Informed Consent - Risks and Benefits

The medical services we provide will be furnished via telehealth. Telehealth is a flexible and convenient way to get healthcare but may not be right for treating certain symptoms or illnesses that need an in-person doctor or urgent care visit. We do not provide emergency care or handle medical emergencies. If you are having a medical emergency, call 9-1-1 or go to the nearest emergency room.

As with any health service, there are potential risks associated with Telehealth. These risks include service problems due to technology or internet failures, not having enough information to make health care decisions, rare security errors, and other risks. You agree to take on the risk for information lost due to technology problems.

Privacy Practices

We use standard physical, electronic, and business security methods to help prevent access to your health information by people who should not see it. But we cannot promise that data sent over the Internet, SMS text, or through a data storage facility will be secure. Although we try to protect your personal information, we cannot guarantee the security of any information you send to us. We may use and disclose your health records as permitted in our Health Information Privacy Practices and by applicable law.

SMS and Email Communications

As part of providing services, we may communicate with you via SMS text messages and email. Text messages and emails are not always secure because they travel over unencrypted networks that we do not control.

By signing below and providing us your cell phone number and email address, you permit us to communicate with you by SMS text message and email. You may ask us to stop sending SMS text messages by contacting us at [email protected]. You understand that you may have to pay data costs to receive SMS text messages that we send to your mobile phone.

Additional Terms

You have the right to communicate grievances regarding you care. Should you wish to make a formal complaint about a Health Professional you may do so in writing and submit the concern to [email protected].

The IL MAKIAGE® website Terms and Use and Privacy Policy are incorporated herein by reference.

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: I have been informed of the following notice:

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

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.

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 (or, alternatively, by accessing this URL in my browser: kbml.ky.gov/grievances/Pages/default.aspx).

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.

New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit medical board’s website, here.

Oregon: 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.

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. I understand that I may be presented with the option to receive services in person, through telehealth, or by audio-only telephone, to the extent clinically appropriate. In the event I receive services by using audio-only telephone, it will be my choice to do so, but I am not prevented from receiving services in person or through telehealth at a later date. Opportunities and limitations of delivering and receiving health care services using audio-only telephone include: convenience and access to care from any location with phone service, but can also reduce the amount of information that is available to my Provider (e.g., such as the availability of medical images, clinical records, etc). If Group is enrolled with my health insurance plan, the services delivered by audio-only telephone will be billed to my health insurance plan, if appropriate. In the event the audio-only services are billed to my health insurance plan, I acknowledge I am financially responsible for any applicable co-payments, coinsurance, and deductibles, and I understand that not all audio-only health care services are covered by all health plans.

Wyoming: 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.