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The undersigned, an adult desiring to undergo an Ayurveda treatment program at vaidyagrama Ayurveda healing village, a unit of Punarnava Ayurveda Limited, 15(1) Rottikaranur Road, Thirumalayampalayam Post, Madukkarai via, Coimbatore 641105 INDIA, hereby acknowledges the following:
Name of patient
Address of patient