Ananda Wellness
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Ayurvedic Consultation Consent form

ANANDA WELLNESS

CLIENT RECORD & CONSENT FORM - ayurvedic consultation

Rear 137, Station St. Fairfield. VIC 3078. Tel: (04) 21674093; ABN: 65972507258

Please Note: These forms are confidential and the information you provide will be used for therapy or consultation reference only.  

Please read the terms of service below and then complete the form in as much detail as possible so that we are able to provide you with appropriate advice/therapy.

 

TERMS OF SERVICE:

Fees: Your service fees will be agreed upon prior to the consultation or treatment

Specific terms of service:

  • You are required to complete a health history form prior to the service

  • Any feedback during treatment or consultation specifically related to new information, satisfaction with or suitability of advice, pain or discomfort is encouraged

  • Late arrivals will lead to a reduction in consultation time

  • If you would like to reschedule or cancel your booking please provide at least 24 hours notice. Failure to arrive for your appointment will incur a cancellation fee of 50% of the appointment fee

Privacy Policy

Any information shared during your session will be held in the strictest confidentiality. All information discussed will not be disclosed to a third party unless required to do so through legal action. In certain circumstances Ananda Wellness Australia may ask your permission to contact your primary physician or other healthcare provider regarding a pertinent medical condition in order to give you the most appropriate level of care.

I hereby request the services of Ananda Wellness for the purpose of providing me with a consultation service. I confirm that all information provided by me is true and accurate. I am satisfied with the terms of service outlined to me and I release my consultant/therapist from any and all liabilities or claims of whatever nature that result from this treatment / consultation or from my failure to pursue medical remedies for any physical ailments I may have, and acknowledge that I have not been dissuaded by my therapist from such prescribed medication. I understand I am free to seek other help from whatever sources I desire.