APPLICATION FOR ADMISSION

1. I hereby authorize KSHEMAVANA SDM INSTITUTE OF NATUROPATHY AND YOGIC SCIENCES to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

3. I understand that technical difficulties may occur before or during the telehealth sessions.

4. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

First name

Last name

Mobile

Occupation

Age

Gender

Preferred Time of Contact

Disease Details with Duration

Any surgery within 6 months?

Any type of allergies

Heart ailment in the past

Present Medication

Reasons you are seeking health care?
Weight loss
Digestive support
Detox
Stress management
Sleep management

Cardiovascular protection
Dietary advice
Pain management
Others

Any Other Information