I hereby confirm that I am undertaking the weight loss education and support program offered by Instinct Health Science LLC DBA iDiet (“IHS”) (“The iDiet Program”) at my own choosing and responsibility. I understand and acknowledge that my participation in The iDiet Program is entirely voluntary and I have not been compelled to participate in it. I understand that The iDiet Program involves regular attendance at groups and some emails and/or video meetings with program staff on issues concerning weight control. I confirm that all information I provide in connection with my health and my participation in The iDiet Program is accurate.
I understand that in the course of participating in group activities associated with The iDiet Program certain personal information (including sensitive information regarding health, medical conditions or lifestyle matters) may be shared by fellow group members. I agree that I will not disclose to any third party any personal information regarding any other participant in The iDiet Program. I also understand that IHS is not responsible for any disclosure of information made to any third party by any participant in The iDiet Program and hereby waive any and all claims against IHS and its affiliates, agents, representatives, employees, directors and stakeholders (the “IHS Parties”) regarding the disclosure by any other participant in The iDiet Program of any personal, sensitive or confidential information pertaining to me.
I also acknowledge that the materials provided to me in connection with my participation in The iDiet Program are confidential and proprietary information of IHS. I agree that I will hold such materials in confidence, will use such materials only in connection with my participation in The iDiet Program and will not disclose such materials to third parties.
I understand and agree that no IHS Party is responsible for, or will incur any liability with respect to, and I hereby waive any and all claims against any IHS Party related to, any health or medical conditions of myself or the participants in The iDiet Program or of any third party.
I understand that I have the right to refuse to do anything IHS personnel or The iDiet Program Staff suggest for weight control and that I may withdraw from The iDiet Program at any time.
I further understand that, subject to any terms to the contrary explicitly set forth in this application, no refund of any amounts paid with respect to my participation in The iDiet Program will be made to me if I withdraw from The iDiet Program.
I confirm that no one on behalf of IHS or The iDiet Program has given me any guarantees about my health or weight loss. I understand that I am responsible for obtaining the recommendation and consent of my physician that I am suitable to participate in The iDiet Program prior to my participation. I understand that my ongoing health and medication use is not the responsibility of IHS or The iDiet Program or any of their respective agents or affiliates, and I am responsible for contacting my physician for medical supervision of all aspects of my health and for any necessary changes in medication use during and after weight loss.
In consideration for my participation in The iDiet Program I release and discharge Susan B. Roberts, IHS and all persons and institutions associated with IHS or The iDiet Program from all claims, liabilities, damages or expenses of any kind which may arise at any time, now or in the future, in connection with my weight control efforts and participation in any program related to IHS or The iDiet, including but not limited to claims based on my health, psychology and wellbeing now or in the future.
I hereby grant permission to Susan B. Roberts, IHS, The iDiet Program, and their employees, agents and assigns to take audio and/or video recordings during meetings of The iDiet Program. I understand that these recordings are intended for the purpose of quality control and will not be released to any non-affiliated third party. I understand that such recordings are the property of IHS and The iDiet Program, and that no compensation is due to me for granting this permission. If Susan B. Roberts, IHS, The iDiet Program staff or any of their respective agents wish to subsequently release such recordings publicly my permission for that separate use will be requested prior to such use and I may refuse to give my consent at that time. My payment and name here confirms my agreement.