CONSULTATION REFUSAL FORM

Patient Name : Date:

Age: Gender: Male/ Female

Contact Number : Time:

Contact number incase of emergency:

Health Issues / Problems:

Hypertension / Diabetes / Cardiac problems / Asthma

I am not willing / interested in undergoing consultation and examination before the

treatment, I have chosen to do ------------------------------------ by my choice and

hold myself responsible for any complications / adverse reaction / event of the

treatment. I will not hold Indus Valley Ayurvedic Centre or its representatives

(Owner, Doctors and Therapists) liable for the same.

Patient Signature Signature - Front Office Staff