Five Goddess Farm Herbal Consultation Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Date

Do You have any allergies? If so, please list.

What Medications are you taking?

Are You taking all medications as prescribed by your physician?

What Supplements are you taking? Please list AM/PM.

Tell me about your activity level. How do you spend your day?

Tell me about your diet.

Tell me about your emotional health.

What are you hoping to address in your visit?

How Did You find Five Goddess Farm?

You are seeking health guidance and hereby attest to the following:

I fully understand that the Five Goddess Farm’s herbalist is not a licensed medical doctor, does not diagnose or treat disease, and that I am not here for medical, diagnostic or treatment procedures. Five Goddess Farm does not make these choices for the guest but provides educational resources in the historic and traditional uses of herbs.
Suggestions and treatments offered for my own well-being and are not intended to take the place of qualified professional medical care, including the diagnosed treatment of named diseases. Please consult your medical care provider before using herbal medicine, particularly if you have a known medical condition or if you are pregnant or nursing.
I am responsible for my own health. As with conventional medicine, herbal medicine is vast and complex, and must be used responsibly. People react differently to different remedies. Some herbs are contraindicated with certain pharmaceutical drugs. Further, some helpful herbs may be confused with harmful and/or deadly substances.
I agree that all nutritional supplements, herbs, extracts, remedies, etc. are taken at my own risk. As with any ingested substance, allergic reaction is a possibility in some individuals. I have been informed of the risks and consequences involved.
I agree that I and my heirs, guardians, legal representatives and assigns will not make claim or file any action against myself or any members of Five Goddess Farm for injury or damage resulting from negligence or other acts, whatsoever, caused in connection with my consultation. I also understand that Five Goddess Farm will not be held responsible for errors/ ingredients on the part of any manufacturer or supplier of products offered.
I have carefully read this agreement and fully understand the content. I am aware that this is a waiver and release of potential liability and a contract between Five Goddess Farmand myself and consent of my own free will.

Signature

Herbal Consultation Intake Form