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Weight Loss Surgery Virtual Support Group Consent Form


I, the undersigned, hereby give my consent and submit my compliance to the use of a third party video conference service for any upcoming Weight Loss Surgery Support Group virtual conference participation, effective immediately and into perpetuity. I further give my consent to the acquiring of my personal information by the virtual conference service provider and storage of my information to data centers located in the United States. 


I fully understand that these virtual meetings will be limited to the participants, but it should be considered public. Their name (as they enter it) may appear on others’ screens as well as their image and voice. As such, that there should be no expectation of privacy and PMC can not guarantee privacy.


Electronic Signature:


Date of Birth:




Pikeville Medical Center