MARMA REGISTRATION FORM

Sri Sri Tattva, Bengaluru

(To be filled in Capital Letters only)

Date District State Practitioner Code

Name
Date of
Age D D M M Y Y Sex Male Female
birth

Address

PIN

Mobile
Email

Profession

Work
address

Do you have any of the following health conditions?

Asthma: Yes No Epilepsy: Yes No Heart Problems: Yes No
TB: Yes No HIV: Yes No Back pain: Yes No
High BP: Yes No Diabetes: Yes No Schizophrenia: Yes No
Pregnancy: Yes No

Do you have any health conditions, other than mentioned above? If yes, please
specify
Are you taking any prescribed medication? If yes, details:
Are you undergoing any psychiatric treatment? If yes, details:
Have you taken Marma therapy before?
How did you know about ‘Sri Sri Tattva Marma’?

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 MARMA REGISTRATION FORM
DECLARATION

I am aware that Sri Sri Tattva Marma treatments are a form of bodywork or traditional therapy or alternative therapy using touch to heal
and rejuvenate the systems in the body. I am also aware that a Therapist of such therapies may also apply touches to a patient's body as a
part of the therapy.

I have independently verified and understood the uses and benefits of Marma therapies. I have of my own volition decided to undergo
treatment of this nature.

I am physically fit to undergo the same... I have accurately filled out the registration form. I have stated nothing false or misleading in
the registration from. I have not suppressed any relevant information.

I hereby assume and undertake full responsibility for my participation for the therapies at Sri Sri Tattva Marma. I agree to abide by all the
rules and guidelines conveyed to me during the course of the therapy. I hereby forever waive, release and discharge Sriveda Sattva (P) Ltd.
and its officers, directors, agents, employees, representatives, the treatment organizers, therapists, any and all other persons connected with
organization and delivery of the therapy from any and all past, present or future claims and/or liabilities for injuries or damages to me in
person and/or property, including those caused by the act or omission of any of those mentioned or others acting on their behalf, arising out
of or connected with my participation in the same. I hereby agree to expressly undertake, assume and accept any and all risks of injury or
death.

I agree that this declaration, consent, waiver and release shall apply to all therapies organized and or facilitated by Sriveda Sattva (P) Ltd.,
including all future therapies, if any.

Patient’s Name and Signature Date

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