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STATEMENT OF INFORMED CONSENT
FOR PARTICIPANTS IN THE 4-WEEK STUDY OF CERUM 7™
I, __________________________ , fully understand that I have an even chance of receiving either 2 bottles of Cerum 7™ or 2 bottles of an inactive product. I agree to use this product daily for a period of 4 weeks according to the instructions on the bottle. I also agree to undergo an initial and weekly examination consisting of the measurements of my weight, body fat, blood pressure, chest, arms, stomach, waist, hips, and thighs and answer a brief questionnaire until the end of the trial.
I will bring my current bottle of Cerum 7™ to the measurements so that the bottle can be measured to assure that I am taking the correct amount of Cerum 7™. The measurements will take place at designated location on four consecutive Saturdays.
My weight loss goal is ________ pounds.
Bottle Number_______________
The time that I will report for four consecutive Saturdays is:
____ 11:30 AM ____ 12:00 NOON
____ 12:30 NOON ____ 1:00 PM
I understand that if I miss any Saturday for measurements or am more than 45 minutes late I will forfeit my right to payment for participation in this study.
_______________________________________
(Signature)
Print Name____________________________________________________ _____
Date____________ Date of Birth_______________
Print Email Address___________________@______________
Daytime phone______________________ Evening Phone__________________
Mailing Address ____________________________________________________
DATA SHEET FOR CERUM 7™ STUDY
