Julie Carestio, PT, DPT Information and Consent to Services

I have read and understand this form and acknowledge that the purposes, goals, techniques and procedures, limitations, potential risks and benefits of the service(s) to be performed have been explained to me.

Further, I have felt free to ask my practitioner questions regarding the proposed services and other pertinent information, including questions about her, and have received satisfactory explanations. I understand that I am free to discontinue service(s) at any time.

I hereby voluntarily consent to herbal, nutritional and wellness consultation with Julie Carestio, PT, DPT. I understand that although Julie is a licensed physical therapist, herbal consultations may be outside the scope of practice for physical therapists. Her herbal training is separate from her physical therapy training. 

Services to be Provided

I understand that herbs are considered to be food supplements and are designed to strengthen and support the body’s natural abilities to heal and deal with stress. Herbs, along with non-medical nutritional suggestions can serve as an excellent adjunct to a medical doctor’s treatment, and I am advised to consult a physician before beginning herbal consultations. An herbalist can neither diagnose nor treat disease in the United States of America.

Risks/Possible Side Effects/Healing Response

Side effects

The historical record and modern research indicate that the herbs most often used for healthcare have exceptional safety records. However, adverse events can occur after using any active substance. Although most “side effects” are nutritive, other side effects have occasionally been reported after using herbs.

These include headaches, skin rashes, and digestive upsets. Such effects generally resolve rapidly, especially if the dosage is reduced or the use of the herb is stopped. Allergic reactions are also very rare but have been reported, usually in individuals with contact allergy to specific plants. Your herbalist may be able to propose measures to reduce any discomforts or may refer you to a licensed practitioner.

Herb-drug Interaction

Although speculative interactions between herbs and drugs are sometimes publicized, confirmed cases are rare. Nevertheless, some prescribed drugs have a narrow range of safe dosage, which makes any interaction (with food, other drugs, supplements, cigarettes, alcohol or herbs) more risky. It is the responsibility of the client to fully disclose any medications currently in use, including other herbs and supplements, so that they can be offered informed advice. Clients are also expected to inform their physicians of any herbs or supplements they are using. Any suggestion 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

Your safety is paramount to my services, and it is my business to stay current with the literature on herbal safety. I will not expose clients to plant doses known to have toxic effects. The organs that are most vulnerable to any potent substances are the liver and kidneys. It will be important for the client to divulge any previous history of disease in either of these organs. Certain herbs should not be used in pregnancy or lactation without expert advice. Clients who become pregnant should stop taking herbs until advice is received.

Information Disclosures

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 guarantee 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 about all aspects of my health, and as service progresses, to inform my practitioner of changes that occur. 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 my practitioner is not a substitute for a medical doctor and will not suggest that I discontinue medical treatment. I am free to consult a medical doctor or any other licensed practitioner at any time. I understand 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.

License or Certification

I recognize that Virginia does not license herbal practitioners and that any statement of credentials is for information purposes only.

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 at least 24 hours in advance, then I am liable for the fee.