Data Privacy Request Form

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IMPORTANT: Form must be completed in its entirety prior to submission. Form submissions with inaccurate or missing information may not be processed.

Are You A California Resident?

What Request Would You Like To Make?

By click Submit Request, I hereby certify under penalty of perjury that I am the consumer whose personal information is the subject of this request. If you are not the consumer but are the consumer’s authorized agent, check the box below and enter your information.

I am acting as an authorized agent for the person named above

Authorized Agent's Phone

If you are an authorized agent acting on the behalf of a consumer in making this request, you must submit proof that the consumer has provided you written permission to submit this request, either in the form of a power of attorney or a written authorization signed by the consumer along with proof of the consumer’s identity. You may do this following the completion of this form by emailing said documents to info@narayanwellness.com under the subject heading "Data Request Documents". If you are an authorized agent, please check the box below.

I hereby certify under penalty of perjury that I am the authorized agent for the consumer whose personal information is the subject of this request.

I declare under penalty of perjury I am the person identified above and the information I provide to this Privacy Portal is true and accurate. *

*Introductory offers valid for first time customers only. Not valid for gift cards. **Rates may vary and offered services may vary depending on availability. Offers, discounts, and/or promotions may not be combined. Certain services are not recommended during pregnancy or for customers with some medical conditions. A doctor’s note may be required. If under the age of 18, parent/guardian signature allowing minor to receive our services is required. Any minor under the age of 16 requires that a parent or guardian remain in the treatment room while services are being performed. Any minor between the ages of 16–17 requires that the parent remain on the premises while services are being performed. See wellness center for more details.

Data Privacy Request Form

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