Kerala Ayurveda Clinic

173 Belgrave Gate Leicester LE1 3HS

Consultation Form


Who should we contact in an emergency?

Health Complaints & Conditions

Have you ever had an Ayurvedic/Complimentary therapies before?
If Yes, please describe
How do you know about us?


Declaration
All the information I have given is accurate and correct and I have not withheld any information about my health. I will keep informed of any changes regarding my health in the future by writing. My Ayurveda Consultant/Therapist has explained the effects and benefits of Ayurveda therapies/Complimentary or beauty therapies and possible effects which may occur as a result; including redness, pain, bruising, some minor reaction and other contra-indications. I recognize that my participation is voluntary and that I am happy to proceed. I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. If I am not able to make a schedule appointment, I agree to cancel the appointment by giving the 24 hours’ notice prior to the booked appointment. If I miss a scheduled appointment without giving 24 hours’ notice, I agree to pay my missed appointment charge.

COVID 19 CHECKLIST

Please answer the following






Declaration
All the information I have given is accurate and correct and I have not withheld any information about my health. I will keep informed of any changes regarding my health in the future by writing. My Ayurveda Consultant/Therapist has explained the effects and benefits of Ayurveda therapies/Complimentary or beauty therapies and possible effects that may occur as a result, including redness, pain, bruising, some minor reaction, and other contra-indications. I recognize that my participation is voluntary and that I am happy to proceed. I have had the opportunity to ask questions and these questions have been answered to my satisfaction. I fully understand the treatment conditions and procedure. If I am not able to make a scheduled appointment, I agree to cancel the appointment by giving 24 hours’ notice before the booked appointment. If I miss a scheduled appointment without giving 24 hours’ notice, I agree to pay for my missed appointment charge.
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