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Informed Consent / Authorization
The following Statement of Client Responsibility; Informed Consent and Authorization sets forth the terms under which The Weight Loss Specialists/Robert Galarowicz LLC is supplying you access to telephonic or electronic consultation services with a Weight Loss Coach and other practitioners and your agreement to accept responsibility for your decision to seek these services thru The Weight Loss Specialists/Robert Galarowicz LLC.
In order to determine your compliance with these Terms, we reserve the right, but not the obligation, to monitor your usage of the services provided. The Weight Loss Specialists/Robert Galarowicz LLC may, in its sole discretion, refuse to provide access to the services due to actual or potential misuse of the site, these Services, or for noncompliance with these Terms.
To fill any service requests, you must verify that you have read and understand these conditions, including the Statement of Client Responsibility.
Statement of Client Responsibility
In submitting my health information in connection with my request for services, the following statements are true:
- I am an adult (at least 21 years of age).
- I am competent to use the services offered by The Weight Loss Specialists/Robert Galarowicz LLC, and I fully understand the nature of the services provided.
- I voluntarily choose to seek a weight loss consultation through The Weight Loss Specialists/Robert Galarowicz LLC.
- I recognize that the consultant reviewing my Health Information may or may not prescribe a diet plan based on my responses.
- I am aware that my failure to provide truthful, accurate and complete information to the consultant and any other providers could result in an inappropriate treatment decision that could be harmful to me or not be safe and effective. Therefore, I have responded to each question truthfully and accurately and have fully and completely disclosed any and all information concerning my health and medical history that could be relevant to my current condition and need for treatment and/or medication.
- I have been seen by a physician and have had a physical examination and/or medical history evaluation within one year of requesting services from The Weight Loss Specialists/Robert Galarowicz LLC. I agree to undergo a physical examination every year to ensure that my request for coaching is appropriate, and to inform my personal physician about the products ordered or purchased, as applicable, thru The Weight Loss Specialists/Robert Galarowicz LLC.
- I will contact my physician if I have questions, difficulties or complications with recommended coaching(s).
- I will make the consultant aware of any changes to my medical condition in the event I return seeking services or products of any kind whatsoever.
- I understand that The Weight Loss Specialists/Robert Galarowicz LLC receives an electronic transmission of my request for a consultation and the reason for said consultation; directs my information to a consultant for his/her review and response in accordance with the consultant’s professional judgment as to my request.
- I understand that I am able to contact the consultant who reviews my information through the customer service number posted on the web site.
- I understand that I will be given the opportunity to ask the consultant any and all questions about any dietary coaching/regimens that may have been suggested for me.
- I understand that the consultant is a Weight Loss Coach; and not a physician.
- I understand that there are risks as well as benefits in undergoing any kind of weight loss regimen or consultation service.
- If paying by credit or debit card, I am the owner of that credit or debit card or I am permitted by law to use such credit card.
Client Agreement and Acknowledgement:
As a customer or potential customer of the services provided by or through this website, I hereby understand, accept, and agree to the following:
In order to determine your compliance with these Terms, we reserve the right, but not the obligation, to monitor your access to and the use of the site and the Services. The Weight Loss Specialists/Robert Galarowicz LLC may, in its sole discretion, refuse to provide access to the site or services due to actual or potential misuse of the site, these Services, or for noncompliance with these Terms.
I am voluntarily providing my health and medical information and completing a telephone interview for the purposes of obtaining services through The Weight Loss Specialists/Robert Galarowicz LLC.
I realize that the consultant will not conduct an in-person physical examination and will rely on the truthfulness and accuracy of the information I am providing during my telephone consultation.
I am using this platform because I am seeking dietary advice from a professional.
I acknowledge that The Weight Loss Specialists/Robert Galarowicz LLC does not practice medicine and is not a healthcare services provider. I further acknowledge that The Weight Loss Specialists/Robert Galarowicz LLC cannot and does not direct, control or influence the opinions or decisions made by the consultant or other assigned clinician with respect to my care.
I agree that any dispute arising out of or related to the provision of services by The Weight Loss Specialists/Robert Galarowicz LLC, by the consultant or other clinician, or by their affiliates, employees, partners and agents, will be subject to mandatory mediation. Should mediation fail to resolve the dispute issue(s), said dispute shall be subject to final and binding arbitration and that all parties will agree to be bound by the arbitration, which will be enforceable in a court and that the parties waive any rights to bring suit in favor of agreeing to binding arbitration.
Any mediation, arbitration, administrative proceedings, or other proceedings shall be held in Bergen County, NJ, unless the parties agree otherwise, and shall be governed by the substantive law of the State of NJ without regard to conflicts of law.
I accept all risks, known and unknown, involved in, arising from or related to using the suggested products or coaching. Subject to and without waiving any rights that may be conferred upon me under state or federal law, I will not seek indemnification and/or damages whatsoever of any kind from The Weight Loss Specialists/Robert Galarowicz LLC for negligent, reckless or intentional acts or omissions, and I hereby hold harmless The Weight Loss Specialists/Robert Galarowicz LLC from and against any and all liability relating to or arising out of my request for or receipt of services from The Weight Loss Specialists/Robert Galarowicz LLC.
I hereby release The Weight Loss Specialists/Robert Galarowicz LLC and the consultant and other clinician from any and all claims that the consultant acted below the requisite standard of care on the basis that the consultant did not personally examine me.
I hereby acknowledge that all information and service provided by or through this web site and telephone service are provided "as is" without warranty of any kind, expressed or implied.
I acknowledge that any and all testimonials and/or reviews expressed by service provider represent only a cross section of the range of results that appear to be typical with these products and/or services. Results may vary depending upon client use and level of commitment.
If any provision of this agreement is held to be illegal, void or unenforceable, then this agreement may be modified or amended only to the extent necessary to enable the remaining provisions to be of force and effect to the maximum degree.
Patient Authorization for Release of Individually Identifiable Health Information
In connection with providing certain individually identifiable health information to The Weight Loss Specialists/Robert Galarowicz LLC, I authorize the following:
I hereby authorize The Weight Loss Specialists/Robert Galarowicz LLC to use and disclose any of my health information, including all individually identifiable health information obtained through documents, forms and/or telephone consultations for the purpose of treatment, payment and health care operations. This authorization additionally includes, but is not limited to, any health information relating to HIV and other sexually transmitted diseases, mental health or disease, drug or alcohol treatments.
The Weight Loss Specialists'/Robert Galarowicz LLC's privacy notice provides more detailed information about our privacy policies, and you are encouraged to review it before agreeing to this authorization.
I declare under penalty of perjury that the foregoing is true and correct. My agreement to this statement constitutes my signature.