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Consent Form

FOR METABOLIC BALANCE PROGRAM AND MEAL PLAN

Introduction


Metabolic Balance is a weight-loss program (the “Program”). The Program involves a customized Metabolic Balance Meal Plan (the “Meal Plan”), for each client based on the individual’s bloodwork. Metabolic Balance, and its Coaches, will not identify, diagnose, nor treat any physical or mental
symptom, disease, disorder or condition. Metabolic Balance is not a medically supervised program, and it is not a nutritional program. The purpose of the Program is to lose weight and/or weight maintenance. The Program has not been evaluated by the Canadian Food Inspection Agency.


The Coach


The Coach will not identify, diagnose, nor treat any physical or mental symptom, disease, disorder or condition.


The Bloodwork


Prior to starting the Program, you will be given a requisition for bloodwork. The cost of the bloodwork is not covered by any provincial health insurance plan. You will be responsible for paying the cost of the bloodwork. Bloodwork is taken solely for the purpose of establishing a Meal Plan.

The results of the bloodwork are not used to identify, diagnose, nor treat any physical or mental symptom, disease, disorder or condition. Should you have any concerns about your health, you must consult your doctor. It is your personal responsibility to share your bloodwork results with your own
doctor.


The Meal Plan


Based on the results of your bloodwork, a customized Meal Plan will be provided to you by the Coach. There are no pills, powders, chemicals, added to your Meal Plan – only food that can be purchased from most grocery stores.


Personal Health Information


In order to prepare your Meal Plan, the Coach will ask you a series of questions regarding your personal health, and this information will be submitted into an online portal, which is based in Germany. Metabolic Balance aims to securely store your personal health information but unforeseen circumstances, such as privacy breaches, can occur. You are voluntarily assuming all of the risks associated with disclosing your personal health information to the Coach and/or Metabolic Balance.


Material Risks


Health risks have been associated with diet and weight-loss. Any weight-loss program may cause conditions such as constipation, dizziness, diarrhea, dry or cold skin, gout, hair loss, headaches, irregular/cessation of menstruation, muscle cramping, loss of lean body mass, and reduced tolerance to cold. Note, this list is non-exhaustive and other side effects may occur. You must discuss any health concerns with your doctor.


Who Is Eligible and Not Eligible


The Program is not suitable for all individuals. It is important that you discuss your decision to follow a weight-loss program, with your doctor. If you are pregnant, intending on becoming pregnant, or nursing, you are not suitable for the Program. Metabolic Balance is unable to create Meal Plans for
persons with severe renal or hepatic insufficiency, or people whose BMI is less than 18. If you have any physical or mental medical symptom, condition, disorder or disease, or are taking any medications, you are responsible for discussing the Program with your doctor before entering into
the Program.


Informed Consent


1. I voluntarily agree to purchase the Program. I voluntarily accept the risks of purchasing and following the Program.


2. I understand that I can decide to stop following the Program at any time.


3. I understand that the Program is not a medically supervised program. I understand that the Program and the Coaches will not identify, diagnose, nor treat any physical or mental symptom, disease, disorder or condition.


4. I am responsible for discussing my decision to follow the Program with my own doctor.


5. I confirm that I do not have any physical or mental symptom, disease, disorder or condition that would be incompatible with following the Program. I am not taking any medications that would be incompatible with following the Program. If I experience any adverse symptoms from following the
Program, I will stop the Program immediately and consult with my doctor.


6. I understand that the bloodwork collected in connection with the Program will not be used to identify, diagnose, nor treat any physical or mental symptom, disease, disorder or condition. I also understand that the results of my bloodwork will be provided by the laboratory to the requesting
Physician, the Coach and its service provider, GET Nutrition Consulting Inc..


The bloodwork results will then be provided to Metabolic Balance GmbH & Co. KG, for the purpose of creating the Meal Plan.


7. I voluntarily disclose my personal information, including personal health information, to the Coach, and Metabolic Balance GmbH & Co. KG, as well as any of their associates, service providers, licence holders, contractors, agents and/or employees, including GET Nutrition Consulting Inc., who may
reasonably need access to this information for the purposes of the Program (e.g., creating the Meal Plan, monitoring quality assurance).


I understand that there are risks involved in disclosing my personal health information, such as data breaches, and I am voluntarily assuming all of the risks associated with disclosing my personal information, health information or otherwise.


8. I have read the above information. I have been given an opportunity to ask any question. All of my questions have been answered to my satisfaction. I wish to proceed with the Program.

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