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Consent Form for In-Person Diabetes Education Classes


Starling Physicians Informed Consent for In-Person Group Meetings 

Purpose: Starling Physicians wishes to provide a neutral setting for patients and community members to attend group meetings to discuss particular conditions or treatment courses. There are many potential benefits to participation, some of which include comfort in knowing that you are not alone, understanding that others have similar concerns and sources of stress, the opportunity to gain perspectives from multiple people, consistency and routine, and motivation to continue in a forward path and reach goals and milestones. 

Potential Risks of Group Meetings: 

Starling Physicians cannot guarantee your privacy when you are participating in a group meeting. 

At times, people may have difficulty reading non-verbal cues from one another and knowing when to speak in order to avoid interrupting others. Please be patient with others and with the facilitators throughout this process. 

Also, please respect that information about group members should not be discussed outside of the meeting. This includes the use of social media platforms. Starling Physicians reserves the right to dismiss group members who violate this policy. 

Participation: 

Your participation in these group meetings is completely voluntary. If you wish to discontinue attending the meetings, you may do so at any time. There is no obligation on your part to attend the meetings, and any decision you make to participate will have no impact on any medical treatment or plan of care with any provider at Starling Physicians. 

Understanding and Consent: 

Starling Physicians is proud to provide this important opportunity to participate in group meetings. 

By completing and signing this consent form, you are confirming: 

  1. I have read and fully understand this document. 
  2. Any questions I had have been answered to my satisfaction. 
  3. I agree to the responsibilities stated above. 
  4. I authorize Starling Physicians to send invitations and meeting materials to my designated e-mail account. 
  5. I do not hold Starling Physicians accountable for unauthorized access to this meeting or any associated information. 

 

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  • Date Format: MM slash DD slash YYYY