Client Consent Form

MANTRA AYURVEDA WELLNESS

Address

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.

GENERAL TERMS OF SERVICE:

• Fees: Your service fees will be agreed upon prior to the consultation or treatments.
• Late arrivals will lead to a reduction in consultation time or treatments.
• 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 up to 100%.
• Rescheduling of treatment sessions will depend on availability and at the sole discretion of the centre.

Requested Services:                                                                               Date:

SPECIAL TERMS OF SERVICE: You are required to complete the attached 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

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 Mantra Ayurveda Wellness 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.

Health History Form

Mantra Ayurveda Wellness Centre promotes health and wellness. There are a lot of benefits that you will get from this type of traditional treatments. However, we would like to inform you that these treatments don’t claim any therapeutic assurance. There are risks involved in this type of treatment especially when you have any existing or pre-existing medical conditions and queries on any such information shall be encouraged and our staff will be happy to assist you.

Do you have any existing medical conditions

• None – I have no pre-existing conditions to declare

• I authorized this wellness centre to perform the treatment or procedure I’ve selected.
• I confirmed that I am of legal age and I’m not under the influence when I signed this consent.
• I authorize the use of lotion, oil, and ointments or any other herbal/ natural preparations to my body.
• I acknowledge that this therapy has no sexual intent and touching the therapist is strictly prohibited.
• I release this this wellness centre for any responsibility in case of an accident, illness, or injury.
• I agree that all information listed below or from another form is accurate and true.
• I confirmed that I do not have any existing medical conditions that can affect the spa treatment.
• I confirmed that I have read the statements above and the staff explained the procedures to me.
• I hereby 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.

By signing below, you confirm that you have read the above, and understand the terms of service, the nature and limits of confidentiality, and what is expected of you as a client.