Please complete this form at least 48 hours before your appointment. I recommend using a tablet or computer. Avoid refreshing your browser, as this will reset the form.

If needed, you can save your progress and continue later using the SAVE bottom of each page. When selected, you will receive an email with a link to your draft submission, allowing you to resume at your convenience.

CONSENT FOR AYURVEDIC CONSULTATION & TREATMENTS

1. Nature of Ayurvedic Consultation
   I understand that Ayurveda is a holistic system of wellness that aims to promote balance in body, mind, and spirit through natural therapies, diet, lifestyle recommendations, herbal supplements and therapeutic treatments. Ayurvedic consultations assess individual constitution (Prakriti) and imbalances (Vikriti) to provide personalised guidance.
   
   
2. Scope of Practice:
   I acknowledge that Ayurveda is complementary to and supportive of traditional western medicine and that it should not replace medical advice, diagnosis, or treatment from a licensed healthcare professional. Ayurvedic Consultations are educational in nature. Ayurvedic practitioners do not diagnose conditions and any recommendations should not be construed as a diagnosis. I understand that I must not forego any ongoing medical treatments without the consent of my doctor.
   
   
3. Pre-Assessment & Treatment Suitability:
   I understand that my suitability for certain Ayurvedic treatments will be determined through a pre-assessment. Based on this assessment, the practitioner may suggest modifications or decline specific treatments for my safety and well-being.
   
   
4. Voluntary Participation & Informed Choice:
   I understand that all Ayurvedic recommendations, including dietary changes, herbal supplements, body therapies, and lifestyle modifications, are voluntary. I accept full responsibility for my choices and will seek medical advice if needed.
   
   
5. Potential Risks & Reactions:
   I acknowledge that Ayurvedic treatments and herbal remedies may have varying effects depending on individual constitution, health conditions, or medication interactions. I agree to inform my practitioner of any pre-existing health conditions, allergies, or medications I am taking. I understand that after beginning an Ayurvedic treatment, it is possible that I may experience a healing crisis (also known as a detox reaction or temporary aggravation). This may include symptoms such as fatigue, digestive changes, headaches, skin eruptions, emotional shifts, or other mild discomforts as my body eliminates toxins and restores balance. These reactions are generally temporary and a sign of deep cleansing. I take full responsibility to promptly inform my practitioner of any concerns so appropriate adjustments can be made.
   
   
6. Confidentiality:
   I understand that all information shared during my Ayurvedic consultation will be kept confidential and used solely for the purpose of my wellness plan, except as required by law.
   
   
7. No Guarantees & Personal Responsibility:
   I acknowledge that Ayurveda is not a quick-fix approach and results may vary based on personal commitment and adherence to recommendations. I take full responsibility for my health and well-being.
   
   
8. Release of Liability:
   I hereby release the Purnam Ayurveda and the associated wellness center from any liability arising from my participation in Ayurvedic treatments and recommendations.
   
   
9. Right to Discontinue Services:
   I understand that either I or the practitioner may discontinue services at any time if deemed necessary.
   
   
10. Practitioner Avaiability between Appointments:
    I understand that the Ayurvedic practitioner may not always be available for immediate consultation. If I have any questions or concerns outside of scheduled appointments, I agree to email them to the practitioner. I acknowledge that responses will typically be provided within 3-5 working days, depending on the practitioner’s availability.

Please record what you eat and drink in a typical day including meal timings: