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            This document is only one part of the process of informing you of the risks of water fasting.  It is not, by any means, the only part of the information process.  Discussions with, and questions to, the involved chiropractors or medical doctor associated with TrueNorth Health, LLC, and with other healthcare providers outside of TrueNorth Health, are an important part of this informational process.  Reading materials, audiotapes and videotapes, all of which are available at TrueNorth Health, are also an important part of this information-gathering process.  We strongly encourage you to ask any and all questions, and to satisfy all your informational needs, prior to your decision to undergo a water-only fast.  We also encourage you to discuss your decision on water fasting with any healthcare provider not affiliated with TrueNorth Health, including your regular physicians.

            First, TrueNorth Health is not a hospital, or medical care facility with a staff of doctors, nurses, etc.  It is a health education program, where participants can reside in its rooms for a short period of time while participating in its programs.  TrueNorth Health has independent doctors of chiropractic, and one medical doctor and a psychologist who assist in its programs.  (For more information on TrueNorth Health and its affiliated healthcare providers, please see our brochure or website.)  But, please be clear that if you have any problems with the fact that TrueNorth Health is not a hospital or a medical care facility, then you should not undergo a water-only fast at TrueNorth.

            TrueNorth Health also compiles medical data obtained from its participants, analyzes this data, and publishes articles regarding this data and research in scientific journals.  These articles do not reveal the identities of any of the participants, but rather only identifies, summarizes and analyzes the medical data.  If, for some reason, you have any problems with the fact that TrueNorth Health compiles data based upon your medical information, and publishes that data in scientific journals, then you should not undergo a water-only fast at TrueNorth Health.

            Next, you should be clear that chiropractors will be assisting you during your fast.  These doctors of chiropractic are not medical doctors.  There is a medical doctor, who is affiliated with TrueNorth, but you will probably be seeing chiropractors much more than this medical doctor. These chiropractors will have access to your medical records, and the medical doctor will be discussing your case with them.  If you have any problems with the fact that chiropractors will be assisting you throughout the majority of your water fast, then you should not under go a water-only fast at TrueNorth.

            Next, while you are water-only fasting at TrueNorth, there are no medical doctors or doctors of chiropractic present during the evenings or at night.  There is a staff person present on site throughout the evenings and night, who can be buzzed from your room to assist you.  But, this staff person is not a medical doctor, doctor of chiropractic, nurse, or other licensed healthcare provider. Your medical records will be available to this staff person.   If you have a problem with the fact that no medical doctor, chiropractor, nurse, etc., will be present on site during the evenings or throughout the night, then you should not undergo a water-only fast at TrueNorth Health.

            Next, you should be clear about the basic definition of a water-only fast: A participant undergoing a water-only fast is consuming only water for the length of the water-only fast.

            You should know that water-only fasting is not accepted by the vast majority of medical doctors and other healthcare providers, including nutritional and dietary experts.  These medical doctors and other healthcare providers believe that water-only fasting has too many risks, which outweigh any possible benefits.  It is only a very tiny minority of healthcare providers who accept water fasting as a valid process.

            There are many risks to water-only fasting and we want you to be aware of them prior to your decision to undertake a water-only fast.  Because you will not be eating any food, you will most certainly experience weakness throughout the water fast, and lose weight.  It can take some time after fasting to regain strength.  A very common occurrence is dizziness and fainting, especially on rising from a laying or seating position.  Other common and unpleasant symptoms are heart arrhythmia, palpitations, dehydration, nausea, vomiting, skin rashes, sore throat, mucus discharge, low back pain, increased menstrual flow, irregular or anovulatory cycles, hair loss, gastric irritation, passing of kidney or gall stones and emotional disturbances.  There is also the possibility of alterations to your body’s basic mechanisms and electrolytes, which could cause heart problems such as a heart attack or vascular problems such as a stroke.

            We cannot and do not guarantee that the water fast will benefit the health condition that you are seeking to improve.

            You should also know that there are alternatives to water fasting, which you are welcome to discuss with any medical doctor or doctor of chiropractic affiliated with TrueNorth, or with any medical doctor, chiropractor, or other healthcare provider not affiliated with TrueNorth.  One alternative is obviously to decide not to do a water-only fast.  Please be clear that we want you to choose to do a water-only fast only if it is your independent decision.  Other alternatives are to undergo a modified fast with the continued consumption of fresh juices and broth or to continue to eat a health promoting diet while participating in our residential health education program.  Other doctors or healthcare providers may have other alternatives to water-only fasting, and you are encouraged to consult with them.

            Please be clear that you can decide not to do a water-only fast, or discontinue fasting at any time.  Do not hesitate to stop the water-only fast, at your discretion, at any time during the fast.  Simply inform us of your desire, so that we can implement that decision.

            We request that you agree to stay on the Center’s property at all times during your water-only fast. Persons fasting must also agree to remain at the Center for a period no less than half the length of their actual fast  —  for refeeding. For example, if your fast lasts two weeks, you must agree to remain at the Center for an additional week for refeeding.  This requirement is for your protection as the recovery from water-only fasting can be a delicate matter.

           All participants must pay for all services at the time they are rendered. Medicare does not pay for services rendered while staying at the Center. Health Maintanence Organizations (HMO) including American Speciality Health Plan (ASHP) do not pay for any services while you are a patient at the Center, except, in some cases, chiropractic manipulation. If an account remains unpaid for more than thirty days, a service charge will be added; and should any action need to be taken for collection, attorney fees will be added to the amounts you owe.

            I, THE UNDERSIGNED, HAVE BEEN INFORMED OF, AND UNDERSTAND, THE NATURE, RISKS, AND POSSIBLE COMPLICATIONS AND CONSEQUENCES OF WATER-ONLY FASTING.  BY MY SIGNATURE BELOW, I CHOOSE AND CONSENT TO UNDERTAKE A WATER-ONLY FAST.

           I HAVE BEEN ENCOURAGED TO ASK QUESTIONS AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED.  I HAVE NEVER ASKED FOR NOR RECEIVED ANY GUARANTEES OR PROMISES FROM ANYONE AT TRUENORTH  HEALTH  AS TO THE RESULTS WHICH WILL BE OBTAINED.

            THIS INFORMED CONSENT FORM HAS BEEN EXPLAINED TO ME, AND I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS AND DO CONSENT TO A WATER-ONLY FAST EVEN IN LIGHT OF THE RISKS OF A WATER-ONLY FAST.

DATED:______________________

YOUR SIGNATURE_____________________________________________