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Informed Consent & General Liability Release Form
[Sign and date at bottom]
Vedic Health Inc
401 E. Jefferson St, Suite 201, Rockville, MD 20850
240-753-0151
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1. The goal of all programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body's ability to heal itself using the principles of Ayurveda.
2. The Vedic Health employee or independent contractor (“Ayurvedic consultant”) is not trained in Western medical diagnosis or treatments, is not a physician, nor a licensed health care professional, but rather a consultant using the principles of Ayurveda to guide the patient with a healthy diet and lifestyle.
3. No medical advice, diagnosis or treatment is given by the Ayurvedic consultant.
4. If you are suffering from a disease or symptom that has not been evaluated by a physician or other licensed health care professional, you must be evaluated by one. If you choose not to see such a provider, by signing this waiver you acknowledge that consultation with a physician has been recommended to you.
5. The Ayurvedic consultant will not alter in any way your prescriptions or other measures, protocols or regimens without written and express approval from your physician or other licensed primary health care provider.
6. Vedic Health Inc holds no liability for any products or supplements that may be suggested, that are not manufactured by Vedic Health Inc.
7. There is a suggested donation for our services. Your donations are tax-deductible. Vedic Health Inc is a registered nonprofit 501(c)3 organization. Retain your electronic receipt. Cancellations should be made 48 hours in advance.
I understand that this consultation and any assessment or information ensuing therefrom is for general educational purposes only and that no claim to medical diagnosis or treatment, or the cure of any medical condition, is inferred or implied. I further understand that this consultation and any recommendations ensuing therefrom should not be construed as a substitute for medical examination, diagnosis and treatment, and that I should see a physician or other licensed primary health care provider for any physical or mental ailment or complaint that I may have. I understand that an Ayurvedic consultation may include assessment of doshic conditions and related recommendations for dietary, herbal or other lifestyle regimens and that these are given from a traditional Ayurvedic perspective only. I understand that any suggestions or recommendations are in no fashion intended as a prescription for any condition. I understand that Ayurvedic consultants are not qualified or licensed to diagnose, prescribe for or treat any physical or mental illness, and that nothing said in the course of any consultation should be construed as such. I understand that any healing process requires my active participation and is my own personal responsibility.
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PANCHAKARMA/AYURVEDIC THERAPY
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1. I understand that Ayurvedic Therapy is an ancient Indian technique that uses the application of herbal oils using various instruments to promote the general well-being of the individual.
2. I understand that Ayurvedic Therapy is not, and is not a substitute for, traditional medical treatment, medications, physical therapy, or massage therapy.
3. I understand that the Ayurvedic therapist, an independent contractor with expertise in Ayurvedic therapies, does not diagnose illnesses or injuries, or prescribe medications.
4. I have clearance from my physician to receive Ayurvedic Therapy which may include application of herbal oils using various instruments.
5. I understand the importance of informing my therapist of any health conditions. I understand that there may be additional risks based on my physical condition.
6. I understand that it is my responsibility to inform my therapist of any discomfort I may feel during the session so he/she may adjust accordingly.
7. I understand that I or the therapist may terminate the session at any time.
8. I clearly understand what Ayurvedic Therapy is and have been given details about my session, have been given a chance to ask questions about it and my questions have been answered.
9. I understand the risks associated with Ayurvedic Therapy include, but are not limited to: allergic response, superficial bruising, muscle soreness, discomfort during procedure. I hereby release the company (Vedic Health Inc) and the individual therapist from all liability concerning these injuries that may occur during the session.
By signing below, I confirm the above statements to be true, and I hereby opt to receive Ayurvedic Therapy offered to me on a donation basis. I understand that after receiving this free service the company may ask for my written feedback.
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