Review of the Consent Form

Detailed below is the proposed draft of the consent form that users must agree to. Ideally, this should be included as part of the agreement process that
prospective customers or patients agree to before they can avail of Seenergie’s services. It may be incorporated in place of the Medical Disclaimer check box:

By ticking the boxes below in this consent form, I hereby warrant, declare and confirm the following statements at the time of my use of Seenergie Lifestyle, Inc.’s (“Company”) Services as defined in the Terms and Conditions:

1. I warrant that I am least eighteen (18) years old and residing in the Philippines.

2. I warrant that if I am acting on behalf of a Dependent as defined in the Terms and Conditions, I am legally entitled to do so within the purview of law and I apprised the Dependent of the nature of services that the Company will provide, including all of the consequences and agreements related thereto.

3. I warrant that all personal information given by me is true, correct, updated to the best of my knowledge, and freely and voluntarily given to the Company and the physician in charge of my teleconsultation/telemedicine (“Physician”).

4. I understand that the license to practice of the Physician with whom I will have my teleconsultation/telemedicine with is only valid in the Philippines.

5. I warrant that I fully agree and consent that all personal data are being collected, used, processed and recorded for purposes of my teleconsultation/telemedicine with a Physician, or my engagement of the Company for any of its Services, and for other purpose as indicated herein. This personal data shall include medical prescriptions, abstracts and orders that may be issued by the Physician, insofar as they may be relevant to the Company’s Services.

6. I warrant that I fully understand that the Company is protecting my personal data in compliance with its Privacy Policy, the Data Privacy Act of 2012, its Implementing Rules and Regulations, other issuances of National Privacy Commission, and other pertinent laws. In line with this, I understand that:

    a. The Company and the Physician shall not disclose my personal information to anyone without my consent, or for unrelated purposes.

    b. I possess all of the rights of a data subject under the Data Privacy Act of 2012.

7. I warrant that I understand my right to withhold or withdraw my consent to the Services any time, without prejudice to any care or treatment I may get through the Company and the Physician in the future.

8. I warrant that I understand and take the risks accompanying my consent to the Services or any other related transactions or consultations with the Company and Physician related thereto.

9. I understand that recording of audio or video and taking of screenshots and pictures are strictly prohibited during the teleconsultation/telemedicine or any other related business transaction(s) conducted with the Company and Physician, unless there is a prior written consent for this purpose executed by me, the Company, and the Physician.

10. I understand that the Company merely provides an online platform connecting me to the Physician in charge of conducting the teleconsultation/telemedicine. As such, the Company will not be privy to nor part of the consultations conducted by the Physician as its role is confined to connecting me to the Physician through its online platform and to providing the medicine prescribed by the Physician in the event I choose to avail of the Company’s Services.

11. I warrant that I understand that the Company does not in any way interfere with and/or participate in any manner in the consultations conducted and prescriptions issued by the Physician. The Physician is solely responsible in providing independent medical support and advice to me.

12. I understand that any prescription issued to me by the Physician after the teleconsultation/telemedicine or any other related business transaction(s) with the Company and Physician, are only based on the personal data I provided and the Physician’s independent assessment of my condition, appropriate method of treatment, and my preferences, and that the same is only valid and effective in the Philippines.

13. I understand that no results can be guaranteed or assured from the Physician’s medical advice and prescription, but the advice and prescription will be provided to the best of the Physician’s capability as a licensed Physician in the Philippines.

14. I understand and agree to the Terms and Conditions and Privacy Policy and any other published policies on the website of the Company.

❑ I have read and understood the information provided above regarding the use of the Company’s Services.

I hereby give my express and informed consent for the use of the Services in my medical care, with full agreement to the Terms and Conditions above, Privacy Policy and other agreements which may be found on the website and other written undertaking with the Company and/or the Physician.