Medical Intake Form

Please complete the Medical Intake Form below. Your responses will remain strictly confidential and will only be shared with the concerned Ayurvedic doctor or other physician(s) who will be involved in designing your treatment program. 

Please be thorough and detailed in your responses. The information you provide is necessary not only to understand your medical history, but also, to diagnose your health issues and to design an appropriate Ayurvedic treatment program. Thank you.