AYURVEDIC MIND BODY CLEANSE

The Ayurvedic Mind-Body Cleanse & Nourish Program is a 2-week program, which involves lifestyle, dietary and herbal suggestions based on your constitution and tendencies. The relationship between the client and health practitioner includes guidance towards achieving a healthy balance within the body and mind. I understand that no diagnoses are made and no treatment for a pre-existing diagnosis will be rendered. This program does not replace a doctor-patient relationship.

All recommendations are meant to be in the client's best interest. This program will provide guidance and direction for clients to participate in a lifestyle - based program designed to address elimination of toxins to help balance natural bodily processes as well as lifestyle advice. While the approach is safe and tolerated very well, I acknowledge that the health practitioner may not be able to anticipate all side-effects and reactions. I understand that I have to consult with my medical doctor if I want to make any changes to any of my medications.

Please note that we are not your primary care physicians. We recommend that you have a primary care physician. Please do not stop your prescription medications without consulting with your prescribing physician.

You have the right to consent, or to withhold your consent, to the collection, use and disclosure of your personal health information, except in specific circumstances where the law authorizes Life In Balance to collect, use or disclose your information without consent.

Life In Balance collects your personal health information directly from you. Life In Balance will not collect more personal health information than is reasonably necessary to meet its purposes.

Our electronic group program and medical record software is compliant with US and Canadian Privacy Acts (HIPAA and PIPEDA). All communication via that platform is private and protected.

Our office will ensure that:

Group Program Exceptions:

I acknowledge that I have read the contents of this Consent Form in its entirety. I agree to accept the program on my own free will and take responsibility for my physical and emotional well-being. I provide consent for participation in this group program for the duration of this program and any future consultations associated with this program.