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Information And Consent To Services For Herbal Consultation

I have read and understand this form and acknowledge that the purposes, goals, techniques, procedures, limitations, potential risks and benefits of the service(s) to be performed have been explained to me. I understand my health information will be used and disclosed consistent with this Notice, and that I have the right to request restrictions on certain uses and disclosures of my health information. Further, I have had the opportunity to ask my practitioner questions regarding the proposed services, this consent form, and other pertinent information, including questions about him or her, and have received satisfactory explanations. I understand that I am free to discontinue service(s) at any time.

Basic Information

Contact Information

Practices Regarding Disclosure of Client Health Information

Services to be provided: I understand that herbs are considered to be food supplements and are utilized to strengthen and support overall health and wellness. Herbs, along with non-medical nutritional suggestions can serve as an excellent adjunct to a medical doctor’s treatment, but are not a substitute for that treatment. An herbalist can neither diagnose nor treat disease.

Risks/Possible Side Effects: The historical record and modern research indicate that the herbs most often used for healthcare have an exceptional safety record. However, adverse reactions and unintended side effects can sometimes occur when taking herbs. Side effects that have occasionally been reported after using herbs include headaches, skin rashes and digestive upsets. Such effects generally resolve rapidly, especially if the dosage is reduced or the herb is stopped. Allergic reactions are also very rare but have been reported, usually in individuals with contact allergy to specific plants. Should adverse reactions or unpleasant side effects occur, I agree to discontinue taking the herbs and contact my herbalist as soon as possible. My herbalist may be able to propose measures to reduce any discomforts or may refer me to a physician or other healthcare practitioner.

Herb-Drug Interaction: Although herbs and other supplements have the potential to interact with pharmaceuticals and certain herbs have been shown to have some effect on a limited range of pharmaceuticals, clinically significant interactions between most herbs and prescription drugs are rare or only potentially possible in theory. Nevertheless, some prescribed drugs are very strong and have a narrow range of safe dosage, which makes any interaction more risky. It is the responsibility of the clients to disclose fully any medications currently in use, including other herbs and supplements. Clients also are expected to inform their physicians of any herbs or supplements they are using. Any indication that the effect of a drug is being altered by simultaneous use of an herb should be reported directly to all health professionals involved. It is also advisable to stop taking herbs at least 48 hours before surgical operations, and in the event of being prescribed anticoagulants, antiepileptic drugs, and digoxin until expert advice is received.

Toxicity: All of the herbs that we use are generally considered safe and non-toxic at recommended doses for most people; however, it is important that the client use the herbs in accordance with the dosage recommended by the herbalist. As the liver and the kidneys are the body organs most vulnerable to any ingested or absorbed substance, it is also important that the client disclose to the herbalist any past or current disease in either of these organs. Herbs should not be used in pregnancy or lactation without advice of a healthcare practitioner and clients who become pregnant should stop taking herbs until that advice is received. I understand and agree that it is important that I do not exceed the recommended dose of the herbs suggested by my herbalist. I also understand and agree to disclose to my herbalist any previous or current liver or kidney disease or related disease as well as any other condition that I believe may have an impact on my health status.

Information Disclosures

Other Professional Competencies: I understand that, should I need additional care from a practitioner licensed to practice another health care profession, I must seek that assistance from a separately licensed professional.

No Guarantees: I know that each person is unique and has ultimate responsibility for his or her own healthcare. I acknowledge that I have not received any guarantees or promises as to the results or success that will be obtained from the services provided.

Client Responsibilities: I understand that it is my responsibility as a client to inform my practitioner of all aspects of my health and that, as service progresses, to inform my practitioner of changes that occur. I will inform my practitioner if I am pregnant and/or suspect pregnancy at any time. If I experience any pain, discomfort or possible adverse side effects, it is my responsibility to immediately notify my practitioner.

Medical Treatment: I recognize that COMPANY/PROFESSIONAL NAME is not a substitute for a medical doctor and will not suggest that I discontinue medical treatment. I understand that if I am currently under a physician’s care, I should continue as long as my physician deems necessary. It is my responsibility to consult with my physician before altering any medications or medical treatments. I understand that COMPANY/PROFESSIONAL NAME may request a physical exam if it has been over a year since my last exam. I am free to consult a medical doctor or any other licensed practitioner at any time. I understand also that if there is an emergency, or a worsening of my health condition, or if a new ailment or condition arises, that I should consult a licensed physician.

Fees and Charges: I have been informed of the fees for service, and I understand that payment is due when the services are provided. If I do not cancel an appointment as least 24 hours in advance, then I am liable for the fee.

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