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The Elements + Ayurveda
Work with me
Pregnancy, Birth + Postpartum
Ayurvedic Chef + Meal Plans
Holistic Support Programs
Online Classes
Mentorships
Journal
Notes On Birth
Mary's ♡ Recipes
All Things Ayurveda
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MARY A WHITLOCK
Home
About
My Story
The Elements + Ayurveda
Work with me
Pregnancy, Birth + Postpartum
Ayurvedic Chef + Meal Plans
Holistic Support Programs
Online Classes
Mentorships
Journal
Notes On Birth
Mary's ♡ Recipes
All Things Ayurveda
Events
Contact
MARY A WHITLOCK
Nurture + Nourish + Ayurveda
Learn More
Hello,
How are you?
In preparation for your upcoming service, please fill out the below form and client waiver .
If you have any questions about any of the fields, please send me an email: mary@maryawhitlock.com or we can go over them when we meet.
Thank you for your time. I look forward to nourishing you!
In good health,
Mary
Name
*
First Name
Last Name
Email
*
How has your digestion lately? Do you frequently experience, constipation, gas, or loose movements? Or are you pretty regular?
How has your sleep been lately? How many hours?
How has your energy level been lately? (on a scale from 1-10 --10 being a lot of energy, 1 being the lowest amount of energy)
Have you been exercising lately? If so what have you been doing? And for how many hours/ day per week?
Do you have any new allergies? If so what?
Do you have a meditation practice? If so how frequently do you you meditate?
Any new therapies, alternative healers + helpers with which you are recently involved?
Have you had any recent serious illnesses/ hospitalizations and or injuries ? If so what?
Do you currently have any pain, stiffness or swelling?
Do you have any new dietary preferences? If so what ?
Is there any food that you currently aren't eating or just DON'T like? If so what?
Any additional comments?
Client Waiver + Release
CONFIDENTIALITY Client information, as well as any notes, images and or videos are confidential, and can only be shared with proper consent from the client. RELEASE FROM LIABILITY You hereby acknowledge and agree that: * You are fully responsible for your diet, healthcare, life and wellbeing decisions for yourself and your family. * I will not be held liable for any consequence to you or your your family resulting from decisions that you make. * I do not make medical decisions on your behalf. * You assume the risks of service, including the risks of trying new foods or supplements, and the risks inherent in making lifestyle changes. *I will not be held liable for any consequence to you or your family resulting from decisions that you make. SAFTEY + DISCLOSURE OF COMMUNICABLE DISEASES. Due to the current pandemic, I request that masks be worn while I’m in your home, keeping in mind social distancing and necessary safety protocols. You agree to disclose any infectious diseases that you or anyone in your household may have. You also agree to immediately inform me if anyone in the home has any symptoms of illness, has had any contact with someone who is sick, or has recently traveled from an affected area so that I can take appropriate precautions If the terms of this Agreement are acceptable, please sign the acceptance in Steps 1 + 2 below . I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
If the terms of this Agreement are acceptable, please sign the acceptance in Steps 1 + 2 below .
*
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
Step 1. Check the box * By checking this box and typing my name below, I am electronically signing the client waiver
*
Step 2. Type in your name First , Last, and Middle Initial as your signature for acknowledgment of the above client waiver.
Thank you!
