PLEASE COMPLETE INITIAL APPOINTMENT FORM BELOW

Name *

First

Last

Date of birth *

DD/MM/YYYY

Postal Address *

House Unit, Street, Zip code, State.

Suburb *

Email *

Contact Number *

Gender

Male
Female
Other

Date of initial appointment at Ayur Health *

Provide the date of the first appointment and NOT the day of form completion

Main Health Concern

Do you have history of chronic health condition in the past or currently taking any medication/ supplements.

Family History: Please select if parents or siblings have suffered from any of the below conditions

How did you know about AyurHealth?

Word of mouth
Internet / Social media
Practitioner referral
Other

Private Health Fund / Provider for Remedial Therapy

Informed Consent: Practitioner may use a variety of Therapeutic, Remedial or Ayurveda massage techniques in your treatment. There is always some risks associated with any health treatment. The best way to reduce the chance of a risk occurring is to answer all the questions about your health, fully and honestly, before treatment begins. The therapist will explain the treatment strategy to you before they commence and outline any associated risks in relation to your condition. If you do not understand, or if you have specific questions, it is important that you ask for further explanation. *

I understand that my health appointment will be provided by an Ayur Health Practitioner and understand that the consultation or treatment I receive is provided for the basic purpose of improving my health.
I have viewed and confirmed the practitioner qualifications
The basic concept of assessment and treatment procedure will be explained prior to consultation/ therapy session.
I can ask questions regarding the techniques being used. I can also ask for techniques to be adjusted to my level of comfort or ask for a technique to cease at any time, for any reason during the procedure.
I can terminate the assessment and treatment procedure at any time for any reason. I also understand that any illicit or abusive remarks or advances made by me will result in immediate termination of the session.
I affirm that I have stated all my known medical conditions, and answered all questions honestly.
The consultation and treatment procedure is intended as a health aid only and does not replace the need for medical emergencies, diagnosis and treatment.
I will seek medical assistance from the appropriate health care practitioner if I feel my health status needs attention. I will not hold the practitioner providing the consultation or Ayur Health clinic responsible for any change in my current health status or any loss or injury resulting from the assessment or therapy session.

Do you agree with the above information? *

Yes
No

You may contact 0470 169 933 and clarify if you have any disagreement.

Electronic Signature: Full name in Block Letters *

Date *

Date of the completion of this form