Participant Informed Consent

 
 

HabitNu Diabetes Prevention Program

I hereby agree to be a participant in the HabitNu Diabetes Prevention program (DPP). I represent that my participation in HabitNu DPP is voluntary. I acknowledge that I have met the program eligibility requirements prior to starting HabitNu DPP. I acknowledge that HabitNu DPP is educational and informational only and assumes no responsibility for the correct or incorrect use of the information. Any information provided and any recommendations made should not be used to, nor are they intended to, diagnose, treat, cure or prevent any existing or future disease and/or medical condition. No attempt should be made to use any information provided as a form of treatment for any specific condition or disease without the approval and guidance of a licensed health physician.

In consideration of my participation in HabitNu DPP for myself, my heirs and assigns, I hereby release HabitNu employees, partners, agents and management from any claims, recommendations, and causes of action arising from my participation in HabitNu DPP.  I agree that if a legal dispute arises concerning my participation in HabitNu DPP or other programs offered by HabitNu, I will attempt to settle the dispute through mediation, and if mediation is not successful, will submit the dispute to binding arbitration conducted in Cook County, Illinois through the American Arbitration Association. I further agree that the laws of Illiois shall apply in any such matter.

As part of your participation in HabitNu DPP, a program for people with pre-diabetes, we may ask that you complete the requested paperwork, surveys, and functional assessments. All responses/outcomes are kept confidential; your responses/performance will not be shared with anyone outside the HabitNu DPP program. The information you provide may be combined with other respondents answers and analyzed and reported in order to help evaluate the program effectiveness, as well as plan future programs. Thank you for your participation in the HabitNu DPP program.