Herbal Consultation Intake Form

Herbal Consultation Intake Form

Herbal Holistic Wellness Minyan Murphy-The Herbal Scientist B.S Forensic Science * M.S Molecular Biology * Master Herbalist
The objective of this form is to outline the responsibilities of the client and the practitioner as they go into a healing partnership. It is provided to promote clarity about the client-practitioner relationship and to outline the standards of practice of an herbalist.
The Responsibility of the Herbal Practitioner

My objective is to help you achieve optimal health and vitality consistent with your own goals to help reverse any symptoms you may encounter. I am not a Medical Doctor nor do I practice western medical assessment, diagnosis, or treatment. I do not claim to cure disease. Nor do I give advice about pharmaceuticals and medications at any time. You are responsibile for your own health. As with conventional medicine, herbal medicine is extensive and complex, and must be used responsibly. Some herbs are contraindicated with certain pharmaceutical drugs.

I have no objections to my clients being seen or evaluated by their personal medical doctor. If you have any questions or concerns about your condition, I highly recommend you discuss it with your physician. I am willing to work as part of a health care team including physicians and other health care providers.

All client records are confidential. I hold all information gathered and discussed with you in strict confidence, unless you request otherwise.
Client Rights and Responsibilities
One time payment for a holistic wellness consultation and herbal medicine of ($200) or ($100) with out herbal medicine is due upon completion of this agreement and is non-refundable. Information you provide based upon your medical background will guide me to formulate the best herbal regimen and holistic approach for you specifically.

Consultation includes herbal holistic suggested products and strategies. After initial completion you may purchase additional products to continue regimen.

All payments will be scheduled and processed immediately. Therefore, Cancellations and refunds WILL NOT be accepted after the submission of the Client Intake form.

*A follow up call or email will be confirmed that I've recieved your intake form

Allow 7-10 days for me to come up with your health plan. I will follow up with my course of action via email.

You can refuse to follow any and all recommendations provided as a result of this consultation. You have the right to choose another practitioner for any reason, and to request that any of your health information be disclosed to another practitioner, or healthcare provider.
Health Demographics
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are your major concerns that you want to address?*
When did the symptom(s) begin?*
Have you had a diagnosis? If so, what was it, when and by whom?*
Are you currently taking any medications, prescriptions, supplements or herbs?*
If you are or were on any medications, prescriptions, supplements, or herbs in the past 6 months please list them all and the dosage.*
How often do you take each medication?*
Do you have any infectious diseases that you know of? If so, please list them.*
Are you pregnant?*
If pregnant, how far along?
Do you have any known allergies or sensitivities? If so, please list them:*
Is there any reason why you could not take remedies made in alcohol (tincture)?*
Have you ever been hospitalized or had any surgeries? If so, please note date and reason:*
Any known family medical history problems from living or deceased?*

Side Effects, Toxicity, Herb-Drug Interactions and Herbal Regulation

The historical record and modern research indicate that the herbs most often used for healthcare have an exceptional safety record. The most common issues associated with herbs are negative herb/drug interactions. I understand the importance of notifying my practitioner of any additions or changes in my prescription medication regime.

Herbs and supplements are regulated by the Food and Drug Administration, under the category of foods.

Most states, including Florida, do not license Herbalists. Therefore I am not licensed, but fully disclose the nature of my practice.
By signing this document I waive any claim for compensation or liability on the part of the herbalist beyond what may be offered freely by the herbalist in the event of such injury, death or medical expenses incurred by me or others.

I acknowledge I am fully responsible for following the recommendations provided by the practitioner and for sharing these recommendations with my primary doctor.

I understand that Minyan Murphy is not a licensed physician and therefore cannot diagnose or treat disease, or prescribe drugs.

I certify that I have read this document, and I fully understand its content. I am aware that this is a client-practitioner agreement and release of liability, and I sign it of my own free will.
Signature*

Clear
Date*

MonthDayYear
Date

My Products

Herbal ConsultationHerbal Plant Medicine Included

$250.00

Herbal Consultation Herbal Medicine Not Included General recommendations and feedback

$150.00

Enter coupon

Total

$0.00

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Herbal Consultation Intake Form

Health Demographics

Personal Health Traits

Health Concerns