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Secure Online Informed Consent Form

At North Star Medical, we use the most advanced security measures to protect your personal informationyour information is encrypted right at your computer, before it even travels across the Internet.

North Star Medical Weight Management
Informed Consent

For use of North Star Medical products in individual counseling, Holiday Survive and Thrive Program, or maintenance and relapse treatment:

The Formula will not be used as my only source of nutrition or calories without consent and supervision of North Star Medical Weight Management.

The Formula will be used only as directed by North Star Medical Weight Management. North Star Medical Weight Management has the right to refuse or discontinue any patient, past or present, who does not comply with the product or programs protocol.

I understand the medical risks involved if I use the Formula without supervision. Therefore, I hereby release North Star Medical Weight Management of liability if I deviate from these conditions. No Refunds or Exchanges.

Patient First Name
Patient Last Name
Address
City
State
Zip Code
Phone
E-mail

Please enter your name again as your electronic signature.

Patient's signature:  
Today's Date: August 21, 2017

I accept the above information as true once submitted.



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