INTRODUCTION This Consent Form is intended to provide the information needed to make an informed decision as to whether or not to undergo the HIIP℠ weight loss program. This document describes the purpose of the program, the procedures followed, possible risks, discomforts and complications, and potential benefits. When you finish reading this form, please indicate your acceptance in the space provided. Please study this form and be sure you understand it completely before making your decision; if you have any questions do not hesitate to ask them and consider the answers carefully. PURPOSE OF THIS PROGRAM The main purpose of the HIIP℠ program is weight loss. It uses the combination of a reduced calorie diet (either a Low Calorie Diet/LCD, or a Modified Calorie Diet/MCD) and a blend of powerful supplementation to facilitate the burning of fat stores, and as a result, to experience weight loss and improved health. The program creates a state of fat burning, and stabilization of blood sugar levels and insulin, which together suppress the normal appetite so that a low calorie diet can be tolerated for an extended period of time. Additional benefits may include a reduction in sugar cravings, improvements in bad cholesterol levels, and a decrease in total body inflammation, which is now known to be a major contributor to many diseases such as diabetes, stroke, and cardiovascular disease. Because the weight loss stages of the diet are relatively low in fat and calorie levels, these stages should not be maintained indefinitely, and you should continue to work with your primary care provider to monitor your health during the program to ensure that participation remains appropriate. Once you achieve your weight loss goal or complete the weight loss stages of the program, a different dietary regimen will be undertaken to transition you into a healthy long-term eating plan, or into a higher calorie interim plan to be followed prior to a return to an additional period of weight loss for those individuals for whom further weight loss is indicated. PROCEDURE You will be asked to review a list of contraindicated medical conditions and other compliance related requirements to ensure your eligibility for the HIIP℠ program. It is critical that you review this list carefully, and only commence the program if you do not have the contraindicated conditions and are willing to comply fully with program requirements. Once you begin the program, you will be provided information on the theory and mechanism of action for the HIIP℠ program, the dietary protocol, the importance of strict protocol adherence, and the supplementation and its uses. To help you reach your weight loss goals, a HIIP℠ representative will be available to answer your questions and to evaluate your progress and results during the program. DIETARY RESTRICTIONS The HIIP℠ program restricts or prohibits consumption of certain items including processed and packaged foods, added sugars, artificial sweeteners and alcohol. Success on the program requires strict compliance with such program guidelines. The program also relies upon the use of natural foods from many food categories. Those with medically dictated dietary restrictions may typically find acceptable food alternatives within the available program food options, but understand that results may be impacted by their restrictions. Those on prescription medications also understand that certain foods may impact the efficacy of those medications, and agree that they have discussed prescription dosages and diet with their personal or prescribing physician. Vegetarians and vegans understand that participation in the program involves substitutions for standard program foods that will reduce the effectiveness of the program, and that food options will be very limited during the course of the program, particularly during the weight loss stages. As such, participation in the program is not recommended for vegans and strict vegetarians. RISKS, DISCOMFORTS AND COMPLICATIONS Reduced calorie diets in weight loss programs have been used for decades and have been shown to be both safe and highly effective. However, as with any dietary program, the process of losing fat releases stored toxins in the body, and hence there always exists some potential for adverse reactions. We stress the fact that given individual biological variation, it is impossible to provide an exhaustive list of every potential side effect that could occur for every individual. With this being said, below are listed the better known side effects from low calorie diets. Headaches – When they do occur they tend to be early in the program, before the body has become accustomed to the new dietary environment. Much like a “caffeine withdrawal”, these are more often due to a “carbohydrate withdrawal.” If headaches continue for more than 5 days, or become increasingly worse daily for 3 days, notify us for evaluation and notify your primary care physician. Mood Swings or Depression – At times, the change in the dietary environment (and associated changes in brain neurotransmitters such as serotonin) can lead to rapid changes in mood or even depression. These mood changes often pass within a few days, but we encourage you to share these experiences with us if they occur, and to discuss with your primary care physician. Confusion – While rare and transient, and often due to temporary decreases in blood sugar or blood pressure, you must notify HIIP℠ if you feel you are experiencing repeated incidences of or an increase in confusion, and should notify your primary care physician. Dizziness – This may occur as your body adjusts to the dietary change, but it can also be a result of insufficient fluid intake, improper spacing of meals/snacks, transient hypoglycemia (low blood sugar), transient hyponatremia (low blood sodium), or transient changes in blood pressure. We encourage you to keep two packets of regular sugar with you at all times. If you experience dizziness along with light-headedness, sweating, weakness, and/or decreasing field of vision, stop any activity immediately and take your sugar packets. If the symptoms improve within a few minutes, the issue likely was hypoglycemia. If not, these symptoms may be due to hydration status or blood pressure changes. They may also be due to inadequate sodium intake. Please notify HIIP℠ and your primary care physician if dizziness remains an issue for longer than a day, or if you experience more than one episode of dizziness, so that we may discuss with you. Blood Pressure Changes – While not common, a very small subset of people may experience changes in their blood pressure, most likely due to the release of stored toxins from the fat temporarily affecting the body’s vascular system. There is no known predictor of susceptibility. Blood pressure may go lower or higher. If you feel symptoms of dizziness, light-headedness, blurry vision, or fatigue, chest tightness, or palpitations, you should check your blood pressure. If your blood pressure is steadily but slowly trending in one direction or another, please contact HIIP℠ and your primary care physician for strategies to halt the trend. If you find that your blood pressure is rising rapidly, or the top number is over 180 or the bottom number is over 110, immediately seek transportation to a nearby ER (do not attempt to drive yourself). Kidney or Gallstone formation – The diet program is low in fat. In some individuals with a predisposition to formation of kidney stones or gallstones, this type of diet may lead to a higher chance of formation of these stones. If this should occur, medical or surgical management may be required. There are no refunds for the HIIP℠ program, and any costs associated with medical or surgical management of this issue (or any other) are the sole responsibility of the member. Pancreatitis – Pancreatitis can occur secondary to the formation of gallstones. Gallstones can block the bile ducts such that pancreatic enzymes for digestion are backed up into the pancreas, in turn causing irritation and inflammation of the pancreas, with symptoms including nausea, upper abdominal pain, abdominal pain that feels worse after eating or radiates to your back, vomiting and abdominal tenderness. Confusion, light headedness, or cognitive difficulties could also be a sign of electrolyte imbalances (hyponatremia). If this should occur, medical or surgical management may be required. There are no refunds for the HIIP℠ program, and any costs associated with medical or surgical management of this issue (or any other) are the sole responsibility of the member. Allergic Reaction – There are multiple supplements utilized in this program to aid the weight loss process, and anyone can be or can become allergic to any component or compound. Call 911 immediately if you experience difficulty breathing, swelling of your face, lips, tongue, or throat. Use oral diphenhydramine (Benadryl) and notify HIIP℠ and your primary care physician of a less severe allergic reaction such as rash, hives, itching or vomiting. Potential for Unknown Drug interactions with Supplements - HIIP℠ involves the ingestion of multiple micronutrients and herbal extracts. Just as certain foods can alter drug absorption and function in the body, the possibility exists for one or more of these herbs to interact with one or more common drugs that an individual may be taking, such that the absorption and/or effectiveness of the drug or the herb could be impacted in a way that causes it to be more or less effective. Many classes of medications, including those for diabetes, blood pressure, birth control, blood thinning, heartburn or stomach acid related issues, cholesterol, and others could possibly be effected by potential unknown interactions due to the changes in diet and ingested supplementation, even though no study may currently exist that documents or proves such interaction. HIIP℠ members hereby acknowledge and accept such risk, and should discuss any concerns they may have with their own physician prior to starting the program. ALTERNATIVES TO HIIP℠ PROGRAM There are several alternatives to the HIIP℠ program, which include other reduced calorie diets, a change in exercise program, prescription medications, liposuction for spot fat reduction and weight loss surgery. Of course you may always choose to take no action. FULL DISCLOSURE I have been fully informed by HIIP℠ representatives that results for the HIIP℠ program are variable from person to person based upon non-measurable biological differences and program adherence, and as such, no guarantees regarding results or duration of results can be provided. I also understand that while HIIP has attempted to outline all the known reactions and side effects related to this program, there is no possible way to list every possible medical event that could occur secondary to this program, and I shall not hold them liable for such. Adherence -- I have been informed that the results of the HIIP℠ program are maximized by following the dietary and supplementation instructions to the letter, and any deviation from those instructions can severely impact my results in a negative manner. Any deviation in following the dietary instructions for the HIIP℠ program (for example, consuming more than the prescribed amount of calories per day or eating foods that are not allowed) can seriously hinder or negate any potential weight loss during the diet time period. Post-Program Diet -- It has been clearly explained to me that my actions during and after the program will fully impact the duration of my results. HIIP℠ has explained to me that after the HIIP℠ program I must gradually return to a different diet that includes a larger amount of healthy fats and carbohydrates, with some dietary restrictions immediately after cessation of the program. I understand that failure to follow these guidelines could lead to rapid reversal of any losses made during the program. Exercise Restriction -- HIIP℠ has explained to me that, because of the reduced calorie diet, extremely heavy exercise is not advised. I agree to refrain from heavy, intense exercise programs during the weight loss phases of the HIIP℠ program, and will perform any other exercise beyond walking with a partner to help ensure my safety. POTENTIAL BENEFITS OF HIIP℠ DIET PROGRAM The most obvious benefit of this program is weight loss. This can help the body to look more balanced and proportioned than it did previously. As weight is lost, many other health parameters may improve. I have been fully informed of the known, possible risks of this program. I understand that, because of the biochemical variability from individual to individual and the role of participant compliance in program outcomes, there are no guaranties or warranties of any kind regarding results or duration of results, and that maintenance of weight loss will depend on a variety of factors including proper diet and activity level. I also understand that I am entitled to receive a copy of this Informed Consent and will request such a copy if it is desired. HIIP℠ certifies that it has made the above disclosures to me or that these disclosures have been made available to me online, has given me the opportunity to ask questions, and has advised me of my right to refuse participation in the HIIP℠ program. I have read the entire above Informed Consent and believe HIIP℠ has adequately explained the risks of this program, alternative methods of therapy, and the possible benefits of this program, and I hereby consent to begin the outlined program. Considering that I have been informed that certain medical conditions and medications prohibit participation in this program, I have provided a full and truthful medical history and a truthful and accurate account of my medications to HIIP℠. Having been apprised of all the above, I have signed this Informed Consent and authorize the subject program. Pre-program and follow-up photographs that may be taken or requested for submission are the sole property of HIIP℠ and may be used for marketing or internal purposes.