I knowingly and voluntarily make the following agreement with Ideal Northwest, LLC (d/b/a Evolve180 Weight Loss), henceforth to be referred to as "Evolve180".
I confirm that the information that I have provided and that is recorded by me on this Evolve180 Health Profile is true, complete and accurate and that I have not withheld or otherwise omitted, whether in whole or in part, any information concerning my health status. In this respect, I confirm that I have disclosed all past and present i) physical and/or mental health problems or concerns that I have experienced, ii) diagnoses and/or surgeries that I have had, and iii) medications and supplements that were prescribed to me or that I have taken.
Without limitation to the foregoing, I specifically confirm that I do not have any of the conditions which are shaded on this form. Furthermore, if I reported having any of the conditions or taking any of the medications specifically printed in bold type on this form, I understand that i) I may need to obtain permission from my physician BEFORE beginning the Evolve180 Program, and/or ii) I may be required to follow specific instructions while on the Program, and iii) I agree to any and all of the requirements as instructed by Evolve180. In the event I am instructed to obtain physician permission before beginning, I agree to i) specifically consult with my medical doctor/ physician about my suitability to go on the Evolve180 Program, ii) remain under the supervision of said physician while I am on the Evolve180 Program, and iii) provide documentation confirming the foregoing.
I understand that if i) I have any of the aforementioned conditions or if I am currently taking any of the aforementioned medications, ii) I have not disclosed same to Evolve180 and iii) I nevertheless chose to go on the Evolve180 Program without specific supervision, such decision will be completely voluntary and I release and discharge Evolve180, Ideal Northwest, LLC, its parent companies, subsidiaries and affiliates and their respective shareholders, directors, employees, agents, representatives, successors and assigns (collectively the "Releasees") from any and all damages, liability, claims and causes of action of any nature whatsoever (including for injury, illness or death) that may result from such voluntary and informed decision.
I confirm that the Evolve180 Weight Loss Program has been explained to me, that I have had the opportunity to ask questions relating to the Evolve180 Program, that I have been provided with the answers to such questions and that I understand the importance of strictly following the Evolve180 Program as explained to me verbally and in the materials provide to me, both before and during the period I will be following the Evolve180 Program.
Without limitation to the foregoing, I confirm that I have been advised that because the Evolve180 Program limits the ingestion of certain foods, it is important that I consume the recommended food, supplements, vitamins and minerals while I am on the Evolve180 Program, and follow instructions for limiting heavy workouts and activity.
I undertake to disclose immediately to my Evolve180 Studio and/or Team any and all changes in my health status, discomfort, symptoms or other health concerns that I may experience while I am on the Evolve180 Program.
I specifically agree that all claims against any of the Releasees that I may have or choose to make shall only be submitted to binding arbitration under the rules of the Arbitration Act or similar statute of my State of residence, and I waive any rights to pursue any claims or causes of action in any court of law.
