Client Form – Hemadri Ayurveda

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COVID Disclaimer

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below. Symptoms of COVID-19 include: • Fever • Fatigue • Dry cough • Difficulty breathing I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.

I understand that this business and my massage therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

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By signing below I agree to each above statement and release the massage therapist and business from any and all liability for the unintentional exposure or harm due to COVID-19. Your massage therapist and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

I hereby request an Ayurveda and Yoga Wellness consultation with Andhrika Kondeti, Ayurvedic Wellness Coach, Practitioner and or Educator for the purpose of educating myself on Ayurveda and Yoga’s approach to wellness in order to enhance my health. I understand that Andhrika Kondeti studied Ayurvedic Medicine for 5½ years at accredited university in India and holds the following degrees and Certificates: BAMS (Bachelor of Ayurvedic Medicine and Surgery), 5 ½ year training in Ayurveda, NTR University of Health Sciences, India (1990-1996) NC. (Nutritional Consultant) Certificate USA (2005) • MH. (Master Herbalist) Certificate USA (2007) LMT. (Licenced Massage Therapist) From Lotus School of Integrated Professions, (USA) 2013-2014 RYT 500 Registered Yoga Teacher) from Bodhi Yoga Training Academy from India, (2015) Affiliated with Yoga Alliance I understand that Andhrika Kondeti has over 20 years of experience practicing and Teaching Ayurveda and Yoga. I also understand that Andhrika Kondeti is not a licensed medical practitioner or a medical doctor in the United States of America. I further understand that I am accepted for participation in this consultation based on the representations and agreements made by me and set forth below:

I fully understand that the sole purpose of this Ayurveda Wellness consultation is for Andhrika Kondeti to assess the level of balance in my physiology according to the principles of Ayurveda, and to educate me on the Ayurvedic approach to enlivening the body’s natural healing processes and restore balance.

I understand that this consultation and any recommendations are not a substitute for a medical examination, diagnosis and treatment for any disease, mental or physical, and I will not modify or suspend any treatment program that I am receiving, without the knowledge and approval of my family physician or specialist.

I understand that any herbal food supplements recommended for me are not drugs. I understand that some herbal food supplements may interact with some allopathic medications; therefore I will consult my physician before taking any herbal food supplements.

Ayurveda herbs/ Herbal formulations or the Ayurvedic consultant are not to be held responsible for any side effects caused by using these products.

ARTICLE IX, U.S. CONSTITUTION “The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the People.” Under the Ninth Amendment to the Constitution of the United States of America, I retain the right to freedom of choice in health educational services. This includes the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy or product recommended by any therapist, doctor, or practitioner of my choice. The enumeration in this declaration of these rights shall not be construed to deny or disparage other rights retained by me, or my right to amend this declaration at any time. to the well being of myself, and my unborn child.

I specifically agree that Hemadri Ayurveda shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on account of, any kind of personal injury, property damage or loss of any kind resulting from or related to my use of the facilities or participation in any exercise or activity within the Yoga Program, and I agree to hold Hemadri Ayurveda harmless from same.

I have read the above release and waiver of liability and fully understand its contents.

I voluntarily agree to the terms and conditions stated above.

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