Confidentiality Agreement Form for:

A Support Webinar for Dr. Gant's Patients, Guardians and Family Members

By signing this confidentiality form I acknowledge that:

1)   I as Dr. Gant’s patient or as a legal guardian to his patient have been invited to Dr. Gant's free Coaching Webinars.

2)   While my attendance is strongly encouraged to improve my contact directly with Dr. Gant and improve my on-going care at NIHA, attendance is not mandatory. 

3)   I am free to opt out of these webinars and that choice will not alter Dr. Gant's clinical recommendations in any way.

4)   Any family members I invite to the webinars are entitled to be privy to my personal information.

5)   Any family members I invite to the webinars have agreed to follow the confidentiality agreements below. 

If I attend these webinars, I agree to the following:

1)   I will use only my first name or the first name of a loved one if I am attending on their behalf, in order to protect my/our confidentiality.

2)   I will maintain confidentiality for all participants, even if they accidentally reveal their full name or personal information, or if I somehow recognize them by virtue of having a previous interaction.

By clicking this registration I agree to the confidentiality agreement above.