Translate This Page

PATIENT CONSENT FORM

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:

  1. That Ayurveda is a procedure which was developed thousands of years ago and has been used in India and other parts of the world, but at present is not universally taught in medical school
  2. That Ayurveda treatments involve careful analysis (requiring detailed personal information), diet and lifestyle counseling,  internal Ayurveda medication, Ayurveda body and detoxification treatments  including but not restricted to abhyanga, udvartana, elakizhi, podikizhi, takradhara, shirodhara,  pizhichil, navarakizhi, sarvangadhara, ekangadhara, snehapana, svedana, vamana, virechana, vasti, nasya, raktamokshana, shirovasti, shirolepa and other such therapies, meditation and breathing therapies, dietary and lifestyle restrictions, and any other process depending upon the practitioner’s judgment of my specific medical need
  3. That I am aware that I should truthfully share all information with my Ayurveda physicians at vaidyagrama; and should not hold back any information with regard to my medical condition that may be useful for the physicians to understand me better
  4. That I am aware that the description of many of the above treatments is given here; if I need any further information in this regard, I will ask my physicians at vaidyagrama
  5. That the above treatment program requires “complete physical and mental rest” which means that I should avoid all activity including but not restricted to travelling, working, reading, internet, talking, using additives like nicotine, tobacco, alcohol etc., eating unwholesome food and any other such activity as given under "advice during treatment" and "treatment - do's and dont's" ; I also need to follow all advice which my physicians give me specifically at each stage of the treatment
  6. That I need to strictly follow the advice given by the physicians without any deviation; I am aware that any deviation can affect my treatment adversely and consequently I may not benefit from the treatments; I further understand that vaidyagrama or my physicians cannot be held responsible for any adverse effects consequent to my disregarding the given advice; I am also aware that if I do not follow the advice given by the physicians and if the physicians become aware of the same, they may decide to discontinue the treatments in my own interest; they may also decide to send me home if I continue to violate the advice given by them
  7. That I am aware that the Ayurveda treatments rendered to me take time to show effect, and depending on my condition, the benefit accrued from this treatment can take many days / weeks / months and perhaps even years; further courses of treatment periodically may also be necessary based on the individual condition
  8. That I am aware that vaidyagrama is not equipped to manage any emergency or surgical conditions; and hence in case of any such requirement, I may be shifted, at my cost, to the nearby Allopathy hospital where the diagnosis and treatment will be rendered as per conventional protocol; at that point I may be required to have my next of kin come and be by my side for the period that I am in the Allopathy hospital
  9. That I am aware that I need to continue my Allopathy medication based on the advice of my Allopathy doctor, and that if I choose to discontinue any Allopathy medication, it has to be under the guidance of my Allopathy doctor
  10. That I am aware that I need to continue to follow the advice rendered by my physicians with regard to my medicines / diet / lifestyle when I return home and I need to be in constant communication with them for the required period to maximize the benefit I get from this program
  11. That I am aware that after the Ayurveda treatment is over, it is best to go home directly and continue to take rest with only essential activity; that it is best not to engage in any travel or touristic activity for a minimum of 4 weeks after the treatment
  12. That I am aware that at vaidyagrama also, it is best to spend at least 7 additional days at vaidyagrama recovering and rebuilding energy after the main treatments are over to enable me to get the best benefits
  13. That I understand that during the administration of Ayurveda treatments, there could be minor adverse effects and/or temporary discomfort including, but not restricted to, lightheadedness, dizziness, nausea, loose stools and fatigue while experiencing and/or recovering from the treatment procedures; and that these adverse effects or discomfort is more often than not due to the state of my own health
  14. That I have been given full information regarding all the costs involved with regard to accommodation, food, treatment, medicines, consultations and other incidentals like telephone, internet, laundry, takehome medicines etc.; I have understood all these costs and I agree to make the full payment in advance on arrival at vaidyagrama. I am also aware of the cancellation and refunds policy of vaidyagrama and I accept the same

I confirm that I have read the above information, or have had it read to me; I have also gone to the pages in the referred links. I understand this information in its entirety including the meaning of all the Sanskrit terms; I have learnt sufficiently regarding the different treatments that I may need to undergo and the diet and lifestyle that I need to follow and am fully satisfied with the description given by the physicians as well as what is there on the website http://www.vaidyagrama.com.

I acknowledge that I am not seeking or undergoing Ayurveda treatments as a result of any inducement or representation or promises made by the Ayurveda practitioner or any of his/her colleagues.

I wish to proceed freely and voluntarily with such treatment and authorize vaidyagrama, a unit of Punarnava Ayurveda Limited to proceed with such treatment with the full and informed consent on my part of all the relevant facts as set forth in this consent form. This consent shall apply to all decisions that the Ayurveda physicians at vaidyagrama take with regard to my medical care

IF YOU HAVE READ THE ABOVE CAREFULLY, THEN PLEASE CLICK HERE TO GO TO THE NEXT PAGE WHERE YOU CAN CLICK ON ALL THE BOXES AND THEN SUBMIT THE PATIENT CONSENT FORM.

Live simple; live well; live healthy; live happy