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PATIENT CONSENT FORM

Please read all the below paragraphs carefully and click on all the check boxes before clicking the SUBMIT button at the very end.

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: