Agreement  and declaration :

I, with complete awareness / consciousness, in full faith / confidence, without any external pressure/ persuasion, of my own accord and freewill, have come to understand –

the signing of this agreement is binding over me and is an assurance that I shall adhere  to all that is stated within it,

that this treatment is to improve the immune system,

that if the immune system is weak, one is more susceptible to disease and if the immune system is strengthened once again, an improvement can be observed in the patient,

that the treatment is a zero – reactive treatment,

that ‘zero – reactive treatment’ means that I shall not suffer any side effects / after effects because of this treatment,

that since no complications can arise because of this treatment, under no circumstance can the treatment or the person providing the treatment be held responsible for any complications that may arise because of mistreatment outside of this treatment,

and state –

that I am in agreement with all that I have come to understand with reference to this treatment,

that if the patient involved is a minor and is unable to make this decision, I as the guardian of the patient, shall take the initiative to do so on the patient's behalf,

that any other treatment that is to be followed during the period in between of which this treatment is being given, shall be followed after the consent of the provider of this treatment has been acquired,

that I shall abide by the code of conduct, demands and procedure for treatment as described to me by the person providing this treatment.

Also if –

any comments which are made with regard to this treatment by me or anybody closely associated to the patient, which are neither neutral nor positive in nature, they can be considered as grounds for having this agreement nullified and for discontinuation of the treatment, without any prior notice / intimation.

the permission of the person providing the treatment is not sought before the start of another treatment during the period in between of which this treatment is being provided, then it can be considered as grounds for having this agreement nullified and for discontinuation of this treatment.

And with regard to the above -

the person providing the treatment may make any relevant amendments to this agreement during and in between the period during which the treatment is being provided to the patient,

if the person providing the treatment feels that anyone associated with the patient has done anything during and after the period of this treatment that is damaging for his self or for the treatment itself, he may approach the court of law under any and all grounds that are provided under it and produce this document as legally binding .

In case of any dispute :

For all purposes with regards to this treatment, “KSCT” stands for Konark  Sampoorn Chikitsa Tantr.

Jurisdiction with regard to any dispute arising in all matters including medicine, dispensing and sending of medicines, payments or remittance of fees, etc., only the Courts and Tribunals having jurisdiction over Bangalore and not over any other place, shall have jurisdiction for the purpose of filing a suit or preferring complaint under the Consumer Protection Act or any other law for the time being in force or taking any legal proceeding against the KSCT or the Dispenser of the medicine.

Dispatch of medicines cannot be claimed as a matter of right.

The KSCT or the Dispenser of the medicine is not responsible for the loss of or the delay in the delivery of medicines - postal or couriered articles sent by the Dispenser of the medicine or by any designated person on behalf of KSCT .

Reminder :

It has been brought to my attention that before procurement of each batch of medicine, the following are to reach the person providing the medication –

The latest pathological reports, the fortnightly progress reports of the treatment

The fortnightly progress reports are to be provided via email or regular post. No telephonic reports shall be considered as the ‘reports’ that are mentioned above.

Initial payments ( Which comprise of : Fees of Consultancy & Profile and cost of one set of medicines ) to be made at the time of Consultancy / Registration.

Subsequent payments should be made at the time of the request or procurement of the medicine.

The person providing the treatment is Mr. Shekhar Gemini.

Name & Signature of Patient / Parent(s) / Guardian(s) :        

1……………………………………………………………………….

2……………………………………………………………………….

Date : …………………………………..