Full Name *DOB *Phone *Email Address *Vital StatisticsHeightWeightHealth InformationYour well-being is our priority. Kindly provide details about any health conditions or concerns.Are you currently on any medication? YesNoIf yes, please specifyHave you had any surgeries or medical procedures in the past 6 monthsYesNoIf yes, please specifyDo you have any medical conditions or allergies?YesNoIf yes, please specifyWellness GoalsYour preferred wellness journey?AyurvedaNaturopathyWhat are your primary goals for visiting us? (Select up to 3)NATUROPATHYDetoxificationGut ResetMental wellnessWeight managementLongevityAYURVEDATridosha balanceRejuvenationPain managementDetoxificationMetabolic disordersHealth and Lifestyle PreferencesTo ensure your experience is tailored to you, please answer the following:How do you feel about fasting or restricted eating patterns?ComfortableNot ComfortableNeutralDo you experience any of the following in your daily routine?Long periods of sitting (desk job, studying) Frequent travelLack of time for personal relaxation or self-careHigh-pressure work or home lifeSocial or emotional stress (e.g., family, relationships, finances)Limited time for preparing healthy mealsIrregular or poor sleep patternsDo you have any dietary preferences or restrictions?VegetarianVeganGluten freeKetoOthers (Please specify):Important Notes or Special RequestsIs there anything else we should know to ensure your visit is perfect?A Personalized Approach to WellnessAfter your visit, our doctor will review your health condition and prescribe a customized therapy and diet plan based on your needs. Whether it's a specific treatment or a holistic lifestyle approach, we ensure that your wellness journey is tailored to support your unique goals and health.Consent & AcknowledgmentBy submitting this form, you acknowledge that all the information provided is accurate, and you consent to receiving wellness treatments at The Aurae Wellness.SignatureContact UsIf you have any questions, feel free to reach out: 📧 Email: enquiry@auraewellness.com 📞 Phone: +919876920044Submit
