Name

First Name

Last Name

Phone

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Your Ayurvedic consultation is for educational purposes. It is designed to:
· Determine your original body/mind constitution or Dosha
· Identify and evaluate any Doshic imbalances that may be present
· Offer you Ayurvedic information and guidance to help you regain and/or maintain your personal balance

 Please bring the following to your consultation:
  1. This Agreement form, signed and dated
  2. Completed Client Information form
  3. Completed Client Personal History form
  4. Ayurvedic Questionnaire, filled out with any uncertain questions left blank
  5. If possible, a picture or pictures of you as a child and/or teenager, also of your parents

  CONFIDENTIALITY OF YOUR PERSONAL INFORMATION IS GUARANTEED.
I understand that this Ayurvedic consultation is intended to educate me about ways that I can improve my own health and well-being following Ayurvedic practices. I understand that it does not offer medical diagnosis or treatment, and is not a substitute for medical care. I have fully disclosed any information on my client intake forms that may affect the Ayurvedic guidance that I will receive. I agree to waive, release, and hold blameless the health counselor for any claim arising out of an injury or for any costs related to an injury arising from participation in this service.

BY TYPING YOUR FULL NAME BELOW, you are signing in agreement to the client statements above.

Today's Date

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Ayurveda Exploration Forms

Welcome to your Ayurveda Exploration Forms.

Please complete ALL FOUR of the following before your appointment.

FORM #1 CLIENT AGREEMENT

FORM #2 CLIENT HISTORY

FORM #3 CLIENT INFORMATION

FORM #4 VIKRITI