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Arrival Date:         Number Nights: Nights  
 
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Application Form for Ayurveda & Nature Cure Therapies
(For information, rules and room tariff please refer to the information brochure / website. All fields are compulsory.)
Name:
  
Gender:
   Male Female
Age:
  
Address:
  
Telephone / Mobile:
 
Email:
  
Occupation:
  
Marital Status:
 
Nationality:
  
Accommodation Required:
 
No. of Days Stay:
  (minimum 7-day stay is required)
Accommodation Required from:
 
to
   
Personal History (please give specific information)
Height:
  
Weight:
  
Appetite:
  
Sleep:
  
Urination:
  
Bowels:
  
Describe your health problems
in detail with duration:
 
Have you undergone any surgery within 6 months?
 
If Yes, give details:
Do you suffer from any skin disease?
 
If Yes, give details:
Have you suffered from heart problems in the past?
 
If Yes, give details:
Whether you are taking any medicines?
 
If Yes, give details:
Can you walk one kilometer without support?
 
If No, give details:
   
Terms and Conditions
  • Management reserves the right of admission
  • Patients are not allowed to go out during their stay unless advised by our doctors
  • Smoking, drinking coffee, alchohol, chewing tobacco are not allowed in the Centre
  • As success of the treatment will solely depend on the patients strictly adhering to the discipline in the prescribed diet, treatments & nature of the health problem / disease, no assurance about cure / recovery can be given.

Undertaking
I have read the conditions mentioned above & those on the brochure / website, all of which i accept & solemnly undertake that i shall abide by the rules & regulations of the Centre faithfully.

In the event of any health complications arising during my stay at the Centre, the management will not be held responsible. The Centre has the right to shift / refer me to a suitable medical institute for necessary treatment at my own cost.
I accept the above undertaking