Ayurveda: Pre-Consultation Form
PLEASE COMPLETE THE BELOW DETAILS
MEDICAL DETAILS
FEMALE HEALTH
DIET & LIFESTYLE
(Please be as honest and accurate as possible. This will help with your personalised treatment plan)
CONSENT
Please read the following information and sign in the box as indicated.
I confirm that I have stated all my known medical conditions and answered all questions honestly.
I understand that the Ayurveda consultations are not involved with the direct treatment of disease or disorders of any kind and they do not substitute for medical diagnosis or treatment.
The Ayurveda Consultant has not made any guarantees or promises regarding the results of these Ayurveda consultations and treatments.
I agree to keep the Ayurveda Consultant informed of any changes in my medical profile during my sessions and understand that there shall be no liability on the Ayurveda Consultant part should I fail to do so.
Treatment may include herbal food supplements as well as other supplementary lifestyle and dietary advice all of which your Ayurveda Consultant is fully trained and insured to carry out. (These will be explained to you prior to their use and where you need further written information, please ask so that this can be provided).
I understand that the herbs are food supplements only and do not replace any other medical treatments or procedures that I am receiving from my General/Practitioner/Hospital/health care professional.
I understand that I must always consult my licensed healthcare provider or physician about any medical condition, suspected medical condition, if I start or stop a medication, and before starting any diet, exercise, or supplementation program.
If I experience any side effects from the herbal food supplements, I will immediately stop taking them and inform the Ayurveda Consultant. No confidential/sensitive details will be passed to any third party without my consent.
I may withdraw my consent verbally or in writing at any time, both for treatment overall, for aspects of a single treatment, and for the sharing of aspects of my case for educational purposes.
Please confirm by ticking the boxes below that you have read and agree to the following. These can be found on The Ayurveda Nest website (www.theayurvedanest.com)