NITHYA SPIRITUAL HEALING - Kailasa Canada

Nithya Spiritual Healing – Consent & Release Agreement

In consideration of receiving services in connection with the Nithya Spiritual Healing process, please complete the following:

NITHYA SPIRITUAL HEALING - CONSENT AND RELEASE AGREEMENT

Practitioner Information

First Name

Last Name

Personal Information

Phone number

Address

Address Line 1

Address Line 2

City

Province

Postal code

Country

Practitioner License Status

Practitioner has informed me, and I am aware, that he/she is not licensed under the laws of this state to practice medicine or provide any other form of health care or the healing arts.

Practitioner is licensed under the laws of this state, but has advised me that the Nithya Spiritual Healing services do not constitute medical diagnosis, care or treatment.

License Type:

Acknowledgments and Consents

Please select all

I acknowledge that the Practitioner has suggested that if I have any physical or mental complaints, I should consult a licensed medical professional or other health care practitioner separately.

I understand that the Nithya Spiritual Healing process is a religious and spiritual prayer and meditation service only and is not a substitute for medical treatment. *

I understand that the Practitioner has not made any representations, guarantees, warranties or promises regarding the outcome of Nithya Spiritual Healing process, particularly with regard to the diagnosis, treatment or prevention of any disease, illness or physical or mental condition. *

I understand that any benefits that I may experience from the Nithya Spiritual Healing process come from within myself. *

I agree to release the Practitioner, as well as Dhyanapeetam, its affiliate Nithyananda Foundation, Life Bliss Foundation, and their Founder Sri Nithyananda Swami, from any and all claims, liabilities and damages arising from the provision of Nithya Spiritual Healing services to me. *

I confirm that I am 18 years of age or older, or I am signing as the legal guardian on behalf of the minor identified below. *

Electronic Signature

By typing your name above, you are providing your electronic signature and agreeing to all terms and conditions outlined in this consent form.

Electronic signature

Date / Time

Nithya Spiritual Healing – Consent & Release Agreement

Practitioner Information

Personal Information

Practitioner License Status

Acknowledgments and Consents

Electronic Signature

KAILASA Canada

Address

Unit 10, 1960 Ellesmere Rd, Scarborough, ON
M1H 2V9

Daily Hours

8:30am – 11am
5:00pm – 9:00pm