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Ayurveda Wellness Consultation is a form of wellness coaching that provides clients with recommendations or suggestions to balance the natural intelligence of the body. 

I understand that Ayurvedic Wellness Consultation is a form of wellness coaching; it does not replace the need for a primary care physician and does not replace any other form of healthcare from licensed physician or healthcare provider.

I further understand that it is my responsibility to seek medical care from a licensed physician for a condition or general wellness in addition to the nutrition, wellness, and lifestyle recommendations that I  receive from my Ayurvdic wellness plan. I also understand that it is my responsibility to discuss any and all information provided during consultations and coaching with my primary health care provider or any other health care providers/specialists whose care I may be under.  

I acknowledge and understand that Kristen Kennedy Smith and Affirmations & Innovations LLC do not claim to cure any disease or condition through the use of Ayurvedic traditional wellness practices.

The services performed by Kristen Kennedy Smith and Affirmations & Innovations LLC are at all times restricted to consultation and coaching on the subject of holistic health, wellness and holistic nutritional matters intended for the maintenance of the best possible state of overall health and wellness and do not involve the diagnosing, treatment or prescribing of remedies for disease. 

Kristen Kennedy Smith & Affirmations & Innovations LLC shall be held harmless and I release Kristen Kennedy Smith and Affirmations & Innovations from all legal liability associated with my wellness decisions based on the suggestions and recommendations I receive during my participation in Ayurvedic Wellness Consulting. 

I understand the risks associated with any wellness program and assume all liability henceforth. 

Due to HIPPA privacy regulations, I understand that my information will be held confidential and not shared with anyone. 

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional Information
Have you received Ayurvedic Wellness Consultation in the past?*
No
Yes
How Did You Hear About Us? *
Website
Instagram
Rose Gold Goddesses
BossBabes
Facebook
A friend or family referral
Other
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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