For the purposes of this from, "you" and "your" mean the individual(s) listed below will attend the Shared Medical Appointment. The use of the words "Lifestyle Medical Centers" means Lifestyle Management Holdins, LLC and its affiliate, RTP Healthy Wellness, PLLC.

By signing this form, you agree to respect other participants by not sharing their medical or personal information outside of this appointment. During your Shared Medical Appointment, you will have the opportunity to meet with a provider to discuss information and ask questions relating to your medical condition. The Shared Medical Appointment will take place in a group setting with other patients present. The personal information shared during an individual appointment is normally considered confidential, but this confidentiality may be lost by revealing the same information in a group setting. Other patients, family members, and other individuals may be present during the Shared Medical Appointment and may hear some of your discussions. It is also important to note that medical information provided in response to another patient’s questions may not be appropriate for all patients.

By signing below and participating in the Shared Medical Appointment, you understand that you are choosing to participate in a group setting and Lifestyle Medical Centers is not able to protect the privacy and confidentiality of what is discussed at the Shared Medical Appointment. Therefore, you agree that Lifestyle Medical Centers shall not be liable for any financial or other damages resulting from the group nature of the Shared Medical Appointment and/or other participants in the Shared Medical Appointment.
In accordance with Lifestyle Medical Centers commitment to maintaining the privacy of its patients, you also agree to protect the privacy of other participants of the Shared Medical Appointment by not identifying other patients or discussing their personal information and/or medical condition outside of the Shared Medical Appointment.

You understand that you or your insurance may be billed for this appointment. You are aware of your responsibility to pay any copays or other costs associated with any services provided in the course of the Shared Medical Appointment that your insurance may not cover.