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Patient Form

Complete the Document Below

Before scheduling your service for Ayurvedic consultation and nutrition consultation, please fill out the required form below.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
Do you have addictions to Coffee, BlackTeam, or Cigaretes or Drugs?
Do any family members have additions problems (ex. drugs, alcohol)?
Did you experience any abuse in your life?
How would youdescribe your digestive system?
How often do you experience these symptoms?


How often do you have a bowel movement?
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  1. An Ayurvedic consultation such as detoxification program (Pancha Karma) are no substitute for medical care and offers no health warranties or guarantees of any kind. 

  2. Always consult a physician before starting any Ayurvedic consultation or yoga or health program,

  3. In subscribing to an Ayurvedic consultation with Om with Anne or registering for classes, events and/or treatments, you agree you do so at your own risk.

  4. This includes recommendations to your diet, health supplements, ayurvedic treatments, yoga therapy or participation in any related activity such as retreats or special events. 

  5. You agree on behalf of yourself and your personal representatives. Here’s executors administrative agents and assigns to the maximum extent permitted by applicable law to release and discharge us and our affiliates employees, agents, representatives, successors, and assigns from any and all claims or causes of action, known and unknown arising out of your or our acts or omissions, including negligence.

  6. This waiver and release of liability’s includes without limitation injuries which may occur as a result of your use of any equipment, any instruction and supervision, received while Om with Anne, you’re slipping and falling, and or therapeutic care in various healing modalities.

  7. Om with Anne is not a medical facility.

  8. The national Institute of health office of complementary and alternative medicine currently considers Ayurveda a form of complementary and alternative medicine in the United States.

  9. Ayurvedic consultations are considered alternative or complementary to healing arts that are licensed by the state of California

  10. No one in association with Om with Anne may recommend altering your treatments or prescriptions without the approval of your physician.

  11. This examination does not take place of a medical evaluation.

  12. Your practitioner may take your blood pressure, check pulse and other vital signs and perform some examination technique similar to a routine, medical examination and is evaluating findings from Ayurvedic viewpoint only and not from a western medical perspective.

Thanks for submitting!

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