Name * First Name Last Name Phone (###) ### #### Email * Are you new to ayurveda? * Yes No What holistic healing modalities have you worked with? * What is your favorite self care practice? * How is your sleep routine? When do you go to bed and wake up? * Do you have a regular meditation practice? yoga practice? * What’s one thing you would like to change about your life today? * Waiver * Ayurveda is a 5,000 year old system of natural healing through diet, lifestyle, and herbs. In Ayurveda, the emphasis is not on disease but on maintaining the balance of an individual’s natural state of wellness. The recommendations are based on one’s unique constitution, designed to incorporate daily foods and lifestyle practices. As a practitioner of Ayurveda, I will provide you recommendations in the following areas: Diet and Lifestyle Counseling, Yoga, Herbal Supplements and Ayurvedic Body Care I have read and understood the above disclosure about the Ayurvedic treatments offered by Melinda Reece. I understand that Ayurvedic Practitioners are not licensed physicians and that Ayurvedic services are not licensed by the state although they are legal. I understand it is my responsibility to maintain a relationship with my medical doctor. I have consented to use the services offered by Melinda Reece and I am informed that herbs may be available for purchase. I understand that I am seeking an educational experience rather than a personal diagnosis of any disease. This educational experience is being provided as teachings based on the principles of Ayurvedic medicine. In consideration of my consultation with Melinda Reece, I agree that I (or my heirs, guardians, legal representatives and assigns) will not make a claim or file an action against Melinda Reece for injury or damage resulting from negligence or other acts, however caused in connection with my consultation. In addition, I hereby waive, release and discharge Melinda Reece from all actions, claims or demands I, my heirs, guardians, legal representatives or assigns, now have, or may hereafter have for injury or damages resulting from my participation in my consultation with Melinda Reece. I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A WAIVER AND RELEASE OF POTENTIAL LIABILITY AND A CONTRACT BETWEEN MYSELF AND MELINDA REECE AND I SIGN IT OF MY OWN FREE WILL. Yes & sign me up to receive Sattva Wellness monthly newsletter Yes Date MM DD YYYY Thank you! New Client Form & Waiver Let's Connect * Let's Connect * Let's Connect * Instagram FOLLOW ALONG Facebook GET INSPIRED Email GET IN TOUCH
