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Herbal Consultation Intake Form

To secure your appointment, this intake form must be completed immediately after scheduling. It only takes a few minutes.
Birthday
Month
Day
Year
How long have you been experiencing this concern?
Less than 1 month
1–6 months
6–12 months
1–5 years
More than 5 years
Have you previously sought medical care for this concern?
Yes
No

Please list any and all prescription medications, over-the-counter medications, supplements, and herbal remedies, you are currently taking.


Allergies and Sensitivities
Yes
No
Medical History

Reproductive Health (if applicable)

Are you currently pregnant?
Yes
No
Are you currently trying to become pregnant?
Yes
No
Are you currently breastfeeding?
Yes
No

Additional Notes

Client Agreement and Disclaimer

By signing below, I acknowledge and agree to the following:


  1. I understand that this herbal consultation is intended to provide educational information and traditional herbal wellness guidance.

  2. I acknowledge that any recommendations offered are based on traditional herbal practice and wellness education and are not medical advice.

  3. I understand that the practitioner is not a licensed medical doctor and does not diagnose, treat, cure, or prevent disease.

  4. Any herbal recommendations or wellness suggestions provided are not a substitute for medical advice, diagnosis, or treatment from a licensed healthcare professional.

  5. I agree to consult a qualified healthcare professional regarding any medical condition and before beginning any herbal protocol, particularly if I am pregnant, trying to become pregnant, breastfeeding, or taking prescription medications.

  6. I understand that herbal remedies may interact with medications or existing health conditions.

  7. I acknowledge that results cannot be guaranteed.


I confirm that the information I have provided in this intake form is accurate and complete to the best of my knowledge.

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Date
Month
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Year
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FDA Disclaimer: These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

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