Client Intake form
Please indicate below any symptoms you have experienced in the last three months:
The Ayurveda Experience provides educational consultancy related to Ayurveda. None of the consultants are licensed physicians, nor is Ayurvedic practice licensed by the state. In order to use our Ayurvedic lifestyle counseling services, it is important that you acknowledge receipt of the information provided in this form and that you sign it, keep a copy for you, and that we keep the one for us for at least three years. Please complete and sign this form, then save it to your device.
Ayurvedic lifestyle modifications are an "alternative“ or "complementary" educational approach to health and wellness which focus on achieving the appropriate balance required for optimal health in the areas of lifestyle (diet & nutrition, physical fitness, etc.), mental well-being (stress reduction, healthy relationships, etc.), and spirituality (religious beliefs, personal philosophies, character development). As a practitioner of Ayurveda, the Consultants will provide you with personal consultations that are educational in nature. They will be based on your personal needs and unique body and mind profile. They may suggest you to read an article or book, inform you about certain vitamins, minerals, herbs, or other supplements, and teach you about how certain changes to your lifestyle or outlook may improve your health and wellness. Their advice may include lifestyle adjustments, dietary changes, herbs, music therapy, and other natural therapeutics. In order to successfully implement these Ayurvedic principles into your life, frequent regular follow-ups are recommended. If you are suffering from a disease or symptom that has not been evaluated by a Medical Doctor or another licensed health care professional, we recommend that you receive a proper evaluation from a registered medical practitioner license to do so. The consultants will be evaluating the findings from an Ayurvedic perspective only and not from a Western medical perspective. This examination does not take the place of a medical evaluation.
NOTE: At any time, should you feel your health is in danger, you should seek immediate attention from a registered and licensed physician.
We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
Health care operations include the business aspects of running this practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer services. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or education about alternatives or other health–related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to your health expert: -
The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. -
The right to reasonable request to receive confidential communications of protected health information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information. -The right to amend your protected health information.
The right to receive an accounting of disclosures of your protected health information.
The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practice with respect to protected health information.
This notice is effective as of July 22, 2022, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post this notice and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of this office. We will not retaliate against you for filing a complaint.