NEW CLIENT FORM — TIFFANAE DAWN

All clients who participate in Ayurvedic health care through this program should be advised of the following

1. Ayurveda is the traditional healing system of India, which is based on the idea that each person's path toward optimal health is unique. Your program is based on understanding your unique constitution and the unique nature of your imbalance. Your program may include lifestyle adjustments, dietary changes, herbs, color therapy, sound therapy, aroma therapy, massage therapy, and other natural therapeutics. The goal of all programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body's ability to heal itself. 2. Tiffanae Dawn Luke is not a medical doctor. 3. Tiffannae Dawn Luke is not trained in Western diagnosis or treatment and may not make suggestions about altering your medical care. 4. In the State of California. Ayurveda is a non-licensed profession. Its practice was formally legalized under the passage of Senate Bill 577 in January 2003. 5. If you are suffering from a disease or symptom that has not been evaluated by a Medical Doctor or another licensed health care professional, we recommend that you receive a proper evaluation and may provide you with a referral form. 6. Tiffanae Dawn Luke will not recommend altering your prescriptions without the approval of your medical doctor. We suggest that you speak to your doctor about reducing medication when he/she feels its appropriate. 7. The findings are evaluated from an Ayurvedic perspective only and not from a Western Medical perspective. This examination does not take place of a medical evaluation. ** I have read and understand the above information and give my permission to begin a program of Ayurvedic health care with Tiffanae Dawn Luke. Please mark YES below **

Electronic Client Signature

Date

1. There is an $85 fee for each consultation with your Ayurvedic Specialist.

2. We do not bill insurance companies for services or herbal formulas.

3. CANCELLATIONS REQUIRE 24 HOURS NOTICE to avoid a full consultation fee of $85.

By applying and submitting the required fields below I am agreeing that I have read and understand the financial policies of Tiffanae Dawn Luke, True Healing and Guidance

Name as it appears on your card

First Name

Last Name

Credit Card No.

Expiration Date

Security CVV

Billing Zip

Electronic Client Signature

Date