Forms
Informed Consent and General Liability Release Form
[Sign and date at bottom]
NOURISH. Carrie Lavie
London Ontario Canada
519-702-4618
1. The goal of all programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body's ability to heal itself using the principles of Ayurveda, Nutrition, and Yoga.
2. Carrie Lavie is not trained in Western medical diagnosis or treatments, is not a physician, nor a licensed health care professional, but rather a consultant using the principles of Ayurveda, Nutrition, and Yoga, to guide the patient with a healthy diet and lifestyle.
3. No medical advice, diagnosis or treatment is given by the Ayurvedic consultant.
4. If you are suffering from a disease or symptom that has not been evaluated by a physician or other licensed health care professional, you must be evaluated by one. If you choose not to see such a provider, by signing this waiver you acknowledge that consultation with a physician has been recommended to you.
5. The Ayurvedic consultant will not alter in any way your prescriptions or other measures, protocols or regimens without written and express approval from your physician or other licensed primary health care provider.
6. Carrie Lavie holds no liability for any products or supplements that may be suggested.
8. I understand that the practitioner may terminate the session/consultation at any time.
7. In case of emergency, please contact your local emergency clinic, hospital, or phone line.
I understand that this consultation and any assessment or information ensuing therefrom is for general educational purposes only and that no claim to medical diagnosis or treatment, or the cure of any medical condition, is inferred or implied. I further understand that this consultation and any recommendations ensuing therefrom should not be construed as a substitute for medical examination, diagnosis and treatment, and that I should see a physician or other licensed primary health care provider for any physical or mental ailment or complaint that I may have. I understand that an Ayurvedic consultation may include assessment of doshic conditions and related recommendations for dietary, herbal or other lifestyle regimens and that these are given from a traditional Ayurvedic perspective only. I understand that any suggestions or recommendations are in no fashion intended as a prescription for any condition. I understand that Ayurvedic, Nutrition, and Yoga consultants are not qualified or licensed to diagnose, prescribe for or treat any physical or mental illness, and that nothing said in the course of any consultation should be construed as such. I understand that any healing process requires my active participation and is my own personal responsibility.
In addition, I hereby waive, release and discharge Carrie Lavie 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 Carrie Lavie.
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS AND CONFIRM THE ABOVE STATEMENTS TO BE TRUE. I AM AWARE THAT THIS IS A WAIVER AND RELEASE OF POTENTIAL LIABILITY AND A CONTRACT BETWEEN MYSELF, NOURISH. AND CARRIE LAVIE, AND I SIGN IT OF MY OWN FREE WILL.
Date _________________________________________________
Name (Please print) ____________________________________
Signature _____________________________________________