WHAT I UNDERSTAND ABOUT MY TREATMENT:
· I can ask questions at any time about Esoteric Yoga or any other class.
· Esoteric Yoga practitioners are not qualified to and nor do they give a medical diagnosis and no esoteric modality offers a cure or any alternative to medical treatment.
· I may withdraw consent at any time.
· I accept full responsibility for participating in a class.
MY CURRENT CONDITIONS:
· Should I have any current illness or injury, however minor, I understand it is my responsibility to make this known to my practitioner prior to attending the class.
· I understand and agree that my attendance at each class is at my own risk and the practitioner takes no responsibility for any injury or loss of any description suffered by me or anyone else as a direct or indirect consequence of my attendance at or participation in any class.
· I recognise and agree that Vicky Geary does not provide treatment or service to anyone with the following Mental Health Conditions, and if I have or have ever been diagnosed with any of these conditions, I may not be able to attend a class. Mental Health Conditions include: Schizophrenia/Bipolar and or states including Mania and Delirium/Psychosis/Borderline Disorder/Major Depressive Disorder.
· I consent to my personal and health information, including my history being:
- reviewed or professionally discussed with other Esoteric Practitioner Association (EPA) accredited practitioners or for medical advice from medical advisors to the EPA Practitioners Committee;
- discussed with other practitioners including, without limitation, my GP, in order to review the quality of care provided to me;
- described in a written or verbal referral to any practitioner, should my practitioner feel that such referral is in my best interests, after having first discussed this referral with me;
- discussed anonymously with other practitioners for the purpose of research and development of esoteric modalities including, without limitation, their integrative qualities with conventional medicine, for the benefit of men and women generally.
MY CONSENT FOR TREATMENTS:
· I consent to the initial and ongoing classes with Amita Khurana
· I agree that this consent form will remain active for future classes and other forms of consultation or advice with this practitioner unless I otherwise notify this practitioner.
· I acknowledge and agree that this practitioner reserves the right to decline any booking (including mine) for attendance at any class, now or later, or to ask a client (including me) to leave any session at any time, for any reason they see fit.
I certify that the information I have provided on this booking form is accurate and complete to the best of my knowledge and I have made full disclosure of all my medical conditions, including current medications.