Consent to Receive Remote ECG Services

QT Medical, Inc. offers a digital, wireless electrocardiogram (“ECG”) system that syncs with mobile devices (both iOS and Android) via Bluetooth technology. QT Medical, Inc. contracts with EKG360, P.C. to offer full 12-lead ECG remote monitoring and interpretation (the “Service”). The portable ECG device receives signals from the one-time use electrode strip applied to the body and then transits that data to a connected mobile device where the ECG reading is displayed. The ECG reading can be shared by the patient with third parties, including the treating clinician. The ECG readings are also stored on QT Medical’s secure cloud server for later access and analysis. Before you give your consent to request the Services, please be aware of how receiving remote ECG monitoring through the QT Medical mobile application (the “App”) differs from an in-person conventional ECG procedure. If you have any questions, please send us an e-mail to support@qtmedical.com or use the “Support” button in the App.

You understand that the Service collects remote ECG readings and does not provide any treatment or other interventions. The Service does not send alerts, either to you or to any third parties. You understand that by using the Services, you will not have an in-person physical exam that might identify a potentially serious medical condition. You understand that you should never use the Services in a medical emergency. You understand that in a medical emergency you should dial 911 or visit an emergency room.

You agree that it is your choice whether or not to use the Services. You understand that at any time, you can change your mind about receiving Services.

You understand that our ECG device has a one (1) year device warranty for any repairs or replacements. The one-year warranty period begins on the date of purchase of the ECG device.

You understand that you will need to pay for Services received through the App yourself and that any insurance you have may not pay for it. You understand that by using the Services, you are freely electing to pay out of pocket and that you may be foregoing discounts or insurance coverage that would otherwise be available to you if you sought care in-person. You understand that it is your responsibility to arrange and pay for any follow-up care.

You understand that if you are using the App, you are responsible for having the latest version of the App on your mobile telephone or device and for having sufficient network or wireless connection to be able to use the App. You understand that you are responsible for accepting and implementing any software patches or updates pushed out through the App.

You further understand that the electronic nature of the Service means that there is a greater risk to the privacy of your electronic health information. By agreeing to use the Service, you are consenting to QT Medical’s sharing of your protected health information with certain third parties as more fully described in our Privacy Policy. In addition to the information you share with us through the App, the App will also collect your device identifier and your geolocation.

This information is necessary to be able to assign your ECG reading to a medical professional licensed in your state. You understand, agree, and expressly consent to QT Medical obtaining, using, storing, and disseminating to necessary third parties, information about you, as necessary to provide Services. Because the Service transmits data over the Internet, it is inherently subject to loss, theft, or corruption. The portable ECG device and the App itself may be vulnerable to viruses, malware, and malfunction. You further understand that records of Services provided to you through the App may be lost through technical failures. You understand that if you are experiencing technical difficulties through the App, you may either send a message through the App or contact QT Medical at support@qtmedical.com. You hereby release and hold harmless QT Medical from any loss of data or information due to technical failures associated with the App or website.

In using the Service, you have the option to have your physician interpret the results of your ECG or to request an interpretation from our contracted cardiologists engaged through EKG360, P.C. Your physician may also request that your interpretations be performed by EKG360, P.C. If your physician interprets the results, a routine ECG reading is typically reviewed within two (2) weeks. If you would like your ECG interpretation sooner than two (2) weeks, please contact your physician’s office during office hours or exchange service for further instructions. You may also request a faster interpretation through EKG360, P.C. through the Site or App. If you select EKG360, P.C. for your interpretation(s), you will be provided with the name, credentials, and qualifications of the licensed clinician providing the ECG interpretation.

If you would like to have the records relating to the Services sent to your primary care provider, you understand that you will need to contact QT Medical through the App or website and request such transfer of records. If you provide your consent to QT Medical providing copies of your medical records for Services rendered through the App, please provide your primary care physician’s information when you set up your account. You may obtain copies of your medical records for Services by contacting us through the App or website.

You understand that the Service is not intended to provide a diagnosis and should not be used in isolation to make a diagnosis of heart disease. Your treating physician should make a diagnosis after full consideration of the clinical record.

By proceeding with purchase of the Services, you hereby acknowledge your receipt, understanding, and agreement to this consent. If you have any questions or concerns about the Services, please contact us at support@qtmedical.com. You understand that this informed consent will become a part of your medical record.