MEPS - Thinnr Qualification Form

If Yes, you will need to discontinue EFA's while on this program.

THINNR WEIGHT LOSS PATIENT DECLARATION

I hereby consent to treatment and guidance while on the Thinnr weight loss program. The Thinnr Weight Loss Program is a medical provider-supervised weight loss program that is designed to maximize weight loss by using specific combinations and blends of specific low glycemic index/anti-inflammatory foods in combination with the Thinnr nutritional support formula. I agree to follow the program designed or modified by the Thinnr supervising health provider. I further agree to attend all scheduled weekly appointments. I also understand that the cost of the program is designed to include the cost of supervision, program materials and supplies.

I agree to the following:

• I will eat every component of every meal as described.

• I will not skip any meals.

• I will take my drops as scheduled and will not miss taking them.

• I will not drink alcohol.

• I will fill out my daily journal to be reviewed at the weekly sessions.

• I will drink my daily amount of recommended water.

• In order to achieve my desired goals, I agree not to quit or give up.

• I will be honest with myself and agree NOT TO DO things that are not in alignment with the program.

I understand that once I have started my weight loss program there are NO refunds. I also understand that my program is NON-transferable.

I understand that weight loss is NOT GUARANTEED with this program, but that other patients have experienced positive results while on the program.

I understand that I undertake this program entirely at my own free will and risk and that my medical provider will endeavor to take all due care.

I understand that my medical provider will rely on statements made by me to determine that the program is safe and will be effective for me.

I have informed the medical provider of all known physical and medical conditions as well as all medications that I am currently taking.

I assume all responsibility and liability for any condition(s) or medication(s) I have failed to disclose.

I hereby waive any potential claim for liability against the medical provider and the makers of Thinnr, and freely accept all liability and responsibility for my results while on this program.

If you are approved for the THINNR Weight-Loss Program, we will send you an invoice for payment of your program and product(s). Once payment is received, we will ship your THINNR products directly to you and provide your next steps, program materials, and instructions to help you get started.