Consultation Form

Mobile

Telephone

First Name

Last Name

testlbl Gender:

Male Female

Date of Birth

Height

Weight

Postcode

Address

Email address

Who should we contact in an emergency?

Full Name

Relationship

Contact No

Health Complaints & Conditions

Fever Acute Infection Disease Recent Haemorrhage Intoxication Chemotherapy Migraine Stress Irregular Periods Asthma

Epilepsy Oedema Radiotherapy Deep Vein Thrombosis Heart Problems Diabetes Insomina Urinary Infections/Diseases Skin Diseases

Circulatory Disorders HIV/Hepatitis B Cancer Thrombosis Recent Operation Varicose Veins Anxiety/Depression Irregular Blood Pressure Dysfunction of Nervous System

Constipation

Pregnancy

Have you ever had an Ayurvedic/Complimentary therapies before?

YES NO

If Yes, please describe

How do you know about us?

Any Allergy or Intolerance

Present Medical Condition

Present Medication

For Consultant Only

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.

Patient Signature

Date

Ayurveda Consultant/Therapist Signature

Date

COVID 19 CHECKLIST

Please answer the following

A. Have you tested positive for COVID-19 in the last 7 days?

YES NO

B Do you have any of the following symptoms?

YES NO

New, continuous cough;

High temperature or fever;

Loss of, or change in, sense of smell or taste?

C Have you been on holiday or outside of UK in the last 14 days?

YES NO

D Have you been to our clinic in the last 4 weeks? If YES, please answer the following.?

YES NO

Is there any change in your health from your last visit to today’s visit? If YES,
please tell us about the change in your health.

YES NO

E Have you been vaccinated? If yes, when did you take the vaccine?

YES NO

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.

Patient Signature

Date

OFFICE USE ONLY

F Temperature

General Data Protection Regulations (GDPR)

1. I consent to the data I have given to be used by for the purposes of documenting and communication in regards to the treatment I am undertaking.

2. I understand the data and information on paper copies will be stored securely and any data stored on electronic devices will be password protected.

3. Only information to my treatment will be held and it will be stored for no longer than necessary

4. My data will not be passed to any third party without my consent

5. I am happy to receive any information on promotions and/or newsletter YES NO

6. I consent to being contacted by:

Email YES NO

Tel YES NO

Kerala Ayurveda Clinic

Who should we contact in an emergency?

Health Complaints & Conditions

Have you ever had an Ayurvedic/Complimentary therapies before?

How do you know about us?

Declaration

COVID 19 CHECKLIST

Please answer the following

Declaration

OFFICE USE ONLY

General Data Protection Regulations (GDPR)