Informed Consent (Ayurveda Procedure)

Date/Time of Consent Discussion: [Date and time]

Date/Time of Signature: [Date and time] (Include only if different from discussion)

Location: [Facility name and setting]

Patient Name: [Full name]

Patient Identifier: [DOB or MRN per facility policy]

Encounter/Visit ID: [ID]

Author: [Name and credentials]

Responsible Practitioner: [Name and credentials] (Include if different from author)

Others Present: [Names, roles, and relationship to patient] (e.g., interpreter, witness, guardian, chaperone)

Decision-Maker and Capacity

Decision-maker: [patient / legally authorized representative (LAR)]. (If LAR: include full name, relationship to patient, and legal basis of authority.)

Capacity assessment: [Capacity assessment findings]. (Explicitly document clinician's assessment that patient demonstrated understanding of information, appreciation of consequences, ability to reason about options, and ability to communicate a stable choice. If capacity uncertain or impaired, describe the factor and steps taken.)

Voluntariness: Consent decision made voluntarily without coercion or undue influence. (If any concern for coercion, document how addressed.)

Communication and Language Access

(Include this section only if communication assistance was used or offered; omit if not applicable.)

• Preferred language: [Language]
• Interpreter services: [offered and accepted / offered and declined / not indicated]. (If used: document modality and interpreter name/ID. If declined: document offer, declination, and patient's stated preference.)
• Accommodations provided: [Accommodations used] (e.g., ASL interpreter, large print materials, simplified explanations, additional time)

Clinical Context

[Working diagnosis or clinical concern prompting procedure, therapeutic goal, and timing rationale]. (If using Ayurvedic diagnostic constructs such as doshic imbalance or ama, include a plain-language explanation of what this means for the patient's symptoms or health goals. Keep concise; this is not a full H&P.)

Procedure(s) Being Consented

(Complete either the Panchakarma Program Overview with component procedures, or Single Procedure blocks as needed. Use plain language plus Ayurvedic terms.)

Panchakarma Program Overview

(Include if consenting for a multi-day program; otherwise omit.)

• Program type and dates: [In-residence / outpatient], [start–end dates], [number of days/sessions]
• Therapeutic focus: [Goals in plain language and/or Ayurvedic rationale]
• Planned components: [List anticipated component procedures]. (Note that final selection, sequencing, and substances may be individualized based on daily assessment.)
• Substance selection: Oils/botanicals/adjuncts will be individualized. Patient will be informed of selections prior to use; allergies and contraindications will be re-verified each day/session.
• Performers and supervision: [Responsible practitioner, assistants/trainees involvement and supervision level]
• What to expect: [General daily schedule, privacy/draping expectations, typical sensations, aftercare expectations]

Component Procedure

(Repeat this sub-section for each discrete component that carries material risk.)

• Name: [Ayurvedic term] — [Plain-language name]
• Body site/route: [oral / nasal / rectal / topical / transdermal / other]
• What will be done: [Key steps, substances/materials, expected duration per session, number of sessions planned]
• Who will perform: [Responsible practitioner, assistants/trainees, supervision level]
• Patient experience: [Expected sensations, privacy and draping arrangements]

Single Procedure

(Use if consenting for a procedure outside a program. Repeat block if multiple single procedures.)

• Name: [Ayurvedic term] — [Plain-language name]
• Body site/route: [oral / nasal / rectal / topical / transdermal / other]
• What will be done: [Key steps, substances/materials, expected duration, number of sessions]
• Who will perform: [Responsible practitioner, assistants/trainees, supervision level]
• Patient experience: [Expected sensations, privacy/draping expectations]

Risk Factors and Contraindications Reviewed

[Patient-specific risk factors identified and allergies relevant to planned substances]. (Document factors such as pregnancy status, bleeding risk/anticoagulants, dehydration/electrolyte concerns, relevant chronic conditions, frailty, GI disorders, nasal/sinus issues, skin integrity. If none identified, explicitly state: "No patient-specific risk factors were identified at this time.")

Benefits, Risks, and Alternatives

(Tailor to the specific procedure(s); avoid guarantees.)

Anticipated Benefits:

[Potential benefits framed as goals relevant to the procedure(s)]. Results vary between individuals; benefit cannot be guaranteed.

Material Risks:

• Common/expected effects: [Procedure-specific common effects]
• Less common but clinically important: [Procedure-specific moderate risks]
• Rare but serious: [Procedure-specific serious risks]
• Patient-specific elevated risks: [Risks elevated by patient factors identified above] (Omit if none.)
• If complications occur: [Immediate steps, urgent contact number, when to seek emergency care]

Alternatives Discussed:

• [Other Ayurvedic options with key pros/cons]
• [Conventional/biomedical evaluation or management with key pros/cons]
• [Watchful waiting/observation with monitoring plan]
• [No treatment — what may happen if declined or delayed]

Questions and Understanding

Opportunity for questions: Patient/LAR had opportunity to ask questions; all questions answered satisfactorily.

Assessment of understanding: [teach-back / other method]. (If teach-back used, summarize key points patient accurately restated in their own words. If misunderstandings occurred, document how they were corrected.)

Sedation/Anesthesia

(Include only if sedation or anesthesia is planned; otherwise state "No sedation/anesthesia planned" or omit entirely.)

• Type: [minimal / moderate / deep / general / regional / local]
• Provider: [Name and credentials]
• Key anesthesia-related risks: [Relevant risks discussed]
• Post-sedation restrictions: [Escort requirements, driving restrictions, activity limits]

Consent Decision

Decision: [consents / declines / defers]. (If declines or defers: document reason if offered, education provided, alternatives offered, and follow-up plan.)

Voluntary informed consent: Benefits, material risks, and alternatives (including no treatment) were discussed. Questions answered. Patient/LAR understands that results are not guaranteed and may withdraw consent at any time.

Trainee involvement: [consents / does not consent] to assistants/trainees performing important tasks under supervision. (Omit if not applicable.)

Signatures

(Do not represent consent as completed until all required signatures are obtained. Mark pending items as "Pending.")

• Patient or LAR: [Printed name] (If LAR: [relationship]) — Signature: [signature / Pending] — Date/Time: [Date/time]
• Responsible Practitioner: [Printed name and credentials] — Signature: [signature] — Date/Time: [Date/time]
• Witness: [Printed name] — Signature: [signature] — Date/Time: [Date/time] (Include if required by facility policy.)
• Interpreter: [Name/ID and modality] — Attestation: [attestation] — Date/Time: [Date/time] (Include if interpreter was used.)

Addendum

(Use for material changes in planned procedures, risks, or timing; for revocation of consent; or when re-consent is required after significant time gap. Omit if not applicable.)

• Date/Time: [Date/time of addendum]
• Summary of change: [Description of change and updated discussion of benefits/risks/alternatives]
• Decision and signatures: [Updated consent decision, patient/LAR signature, practitioner signature, witness/interpreter if applicable]