Informed Consent for Ayurvedic Therapy & General Liability Release Form

 

[Sign and date at bottom]

Vedic Health Inc

401 E. Jefferson St, Suite 201, Rockville, MD 20850

240-753-0151

www.vedichealth.org

General Liability Release Form 

By signing below, you agree to the following: 

PANCHAKARMA/AYURVEDIC THERAPY

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.

I have read and agree to the above Liability Waiver: