World Health Organization (WHO): “Medicines are rationally used if patients receive medications appropriate to their

clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest
cost to them and their community.”

Functional Medicine Institute Pvt. Ltd.

Registered Office at #40, Ground Floor, VJ Infiniti Apartment, 2nd cross Doctor's Layout, Opp.
Government School, Kasturi Nagar, Bengaluru, Karnataka 560043

KEY PERSON
Dr. Ashwani Garg, M.B.B.S, (Functional Medicine Practitioner)
MCI Registration: 11- 39419
Contact No.: +91-9916374381 Website: www.functionalmedicineclinic.in
Email: info@functionalmedicineclinic.in

CONSENT CUM AUTHORISATION FOR MEDICAL CONSULTATION/ TREATMENT

(NON-SURGICAL/ NON-INVASIVE/ NON-SEDATIVE)

Deepu Selvaraj
Patient name: _________________ A Selvaraj
s/d/w of________________
25-Aug-1987
Date of birth: ___________________ Male
Gender: ______________
B-1405, Myhna Heights, SH-35, Varthur Main Road, Gunjur, Bangalore-87
Address:_____________________

9591881367
Contact No. _________________
B.Tech
Education: ______________ Manager
Occupation: ______________

Uric Acid,Gout, Weight

Diagnosis/ Chief Complaints: ______________

7-8 years
History of the Disease: ______________ (__years old)
Nil
Current medications: ______________

Unkown
Known allergies: ______________

1. I hereby authorize Dr Ashwani Garg and those whom he may designate as associate or assistants,
to translate and execute his instructions, to evaluate the reports and medical history for dispensing a
personalised treatment plan.

2. I have understood that Functional Medicine is a different approach from the existing health care
model.

3. I have understood that the disease under treatment is a chronic condition and that Functional
Medicine Clinic does not handle acute health conditions.I will need a Primary Care Physician/Family
doctor to attend to any of my medical emergencies while on treatment with Functional Medicine
Clinic.

4. Following has been fully explained to me and I have understood the same:

a) Dr Ashwani Garg may use complementary, integrated, non-traditional, holistic/Functional

Medicine methods during treatment.

1
 b) The nature and duration of the treatment, tentatively and without break.
c) Expected outcome of the treatment (subject to body response).
d) The kinds and possibilities of detox and die-off reactions in the treatment.
e) I understand that if I experience any such reactions, I am responsible for following up with
my physician at my expense. Occurrence of complication carries no indemnity.
f) I have also understood that my voluntary or unavoidable discontinuation of the treatment at
any stage before the completion of the duration may not give me any or proportionate relief.
g) This possible alternative method of treatment has been discussed and I have chosen this
option and accepted the present recommendation as the treatment of choice of my own
free will, without any inducement or undue influence of any kind whatsoever.
h) My present consultants shall describe and decide upon any second opinion or expert
opinion, referral, or to simultaneously take, if required at any stage.

6. This consent of mine shall hold and bind me to any change in prescriptions, or modification of
treatment, at any stage as per the clinical judgment of my present consultants and would ratify the
same without any fresh consent form being filled in, unless a new disease is discovered or impacted.

7. I understand that any side effects include, but are not limited to, failing to properly administer the
medication/supplement, failing to observe side effects, failing to assess and/or recognize an adverse
reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to
summon emergency medical services.

8. I do hereby fully release or discharge Functional Medicine Institute Pvt. Ltd, Dr. Ashwani Garg and
his associates or assistants from any and all claims from injuries, damages and losses I may have, or
accrue, and arising out of, connected with, incidental to, or in any way associated with the treatment.

Having understood all of above, and after having raised my own questions, concerns, doubts,
clarifications, I am ready and willing to undertake the treatment and give my consent for starting the
treatment after satisfactory consultation, which I am aware of, depends on my strict compliance and
follow up of the clinical advice given from time to time.

I am signing this consent after having been counselled on my presenting condition(s) and after
having been explained the treatment options, in my vernacular as well.

S.Deepu
Signature of patient (if major)/ Parent/ Guardian (if minor)

10-jUNE-2024
Date:___________

21:00
Time: ___________

x-------x`

Dr Ashwani Garg Date: _______

Functional Medicine Institute Pvt Ltd Time: _______

(ALL DISCLOSURES WERE MADE TO THE PATIENT AS PER BEST PROTOCOLS & PRACTICES)