Ayurvedic Consultation Intake Form

Informed Consent

  1. The goal of all programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body’s ability to heal itself using the principles of Ayurveda.
  2. An Ayurvedic consultant is not trained in Western medical diagnosis or treatments; he or she is not a physician, nor a licensed health care professional, but rather an Ayurvedic consultant using Ayurveda.
  3. No medical advice, diagnosis or treatment is given by the Ayurvedic consultant.
  4. If you are suffering from a disease or severe symptom that has not been evaluated by a medical doctor or another licensed health care professional, you must be evaluated by a medical doctor. If you choose not to see a medical doctor, by signing this understanding you acknowledgement that consultation with a medical doctor has been recommended to you.
  5. An Ayurvedic consultant will not alter your prescriptions without approval from your medical doctor or other licensed primary health care provider.
  6. The consultant holds no liability for those supplements not prepared or manufactured by her.

I understand that this consultation and any assessment or information ensuing thereafter is for general educational purposes only and that no claim to medical diagnosis or treatment, or the cure of any medical condition, is inferred or implied. I further understand that this consultation and any recommendations ensuing thereafter should not be construed as a substitute for medical examination diagnosis and treatment, and that I should see a medical doctor or other licensed primary health care provider for any physical or mental ailment or complaint that I may have. I understand that an Ayurvedic consultation may include assessment of doshic conditions and related recommendations for dietary, herbal or other lifestyle regimens and that these are given from a traditional Ayurvedic perspective only. I understand that any suggestions or recommendations are in no fashion intended as a prescription for any condition. I understand that Ayurvedic consultants are not qualified or licensed to diagnose, prescribe for or treat any physical or mental illness, and that nothing said in the course of any consultation should be construed as such. I understand that any healing process requires my active participation and is my own personal responsibility.

I have read and understand the above information.