Health Intake Form

Please take the time to fill out this form before your appointment.

Statement of Understanding

I understand that an Ayurvedic Health Counselor and Educator provides me with information on the Ayurvedic approach to health care, which may affect my diet and health in a positive way. I understand that he/she is not a medical doctor or licensed medical practitioner, has not presented themselves as such, and does not seek to diagnose, treat, or prescribe for diseases, disorders, or other pathological conditions. I agree that I am interested in enhancing my own abilities to heal and establish health in mind and body, and this is the reason I have sought this Ayurvedic Health Counseling service. I agree that I may consult a licensed physician for any concern, at any time, about any disease or pathology, which now exists or arises at any time during the professional relationship with an Ayurvedic Health Counselor. Furthermore, I understand that Ayurvedic Health Counselors encourage regular medical checkups from a licensed medical professional of my choice, and that any medication that I am now taking upon my licensed physician’s advice, or will take in the future, is taken strictly according to my licensed physician’s directions, and that only a licensed physician of my choice can advise on medication dosage or the discontinuation or resumption of such medication.

By checking the box above, I acknowledge the above statements as fully read and understood.