Online Consultation Form
Fee: $ 100 Canadian Dollars, "SERIOUS INQUIRIES ONLY".
Browser: Internet Explorer may be better browser and may not give you any "Error" messages.
Payment: Strictly Credit Cards (upon receiving this form, first we will ask your credit card information). Please provide proper information regarding your health matters, it will be better for us to give you proper advice & guidance. If you are not a patient and filling form for other man/woman, you must notify him/her.
Browser: Internet Explorer may be better browser and may not give you any "Error" messages.
Payment: Strictly Credit Cards (upon receiving this form, first we will ask your credit card information). Please provide proper information regarding your health matters, it will be better for us to give you proper advice & guidance. If you are not a patient and filling form for other man/woman, you must notify him/her.
i understand the assessment of my health problem(s), and providing all information above is correct to get right health advice from Ayurvedic LifeStyles Inc. with personal interest. It is entirely my choice of these services. i am / will agree with Ayurvedic LifeStyles Inc. terms & conditions. An accurate health history is important to ensure that it is safe for you to receive massage or any other treatment. If my health status changes in the future, i must let Ayurvedic LifeStyles Inc. know. All information gathered for this treatment(s) is confidential except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment. By signing below this form, i have written authorization to do so to release my information. i understand that these therapies is not intended to replace allopathic methods of treatment, nor is it meant to be diagnosis or cure. Ayurvedic Lifestyles Inc. (Ayurved Centre, and IIACM Inc.) its owner, teachers, practitioners, staff and all other personnel won’t be liable whatsoever, resulting from any injury, or loss or personal items, i may have sustained while on/off their premises. i will be agreeing to future Credit Card charges and upon filling-up this form and submission Ayurvedic LifeStyles Inc. has right to bill/invoice appropriate fee and collect it from me, otherwise Ayurvedic LifeStyles Inc. has rights to forward/release my case to the authorized collection agency.
