Mini Consult Intake Form

Mini Consult Intake Form

This form is secure, HIPPA Compliant, and will only be seen by The Elderberry staff.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Gender
Sex at Birth
Occupation
Primary Concern
Physicians’ diagnosis (past and present)
Medications (Including over the counter):
Hormonal Birth Control (past and present):
Herbs/Supplements taken regularly:
Allergies (medications, food, environmental):
Have you had Covid-19?
Are you sober or in recovery?
Please indicate your average energy level if 0 is low and 10 is high:
Please indicate your quality of sleep if 0 is poor and 10 is excellent:
Please indicate your average stress load if 0 is low and 10 is high:
Do you run Hot or Cold?
Do you adhere to a specific dietary protocol?
If "other," please explain:
Do you consume the following?
Are you often thirsty?
Other Relevant Information:

Agreement for Consultation and Formulation Services
This agreement for consultation and formulation services is made by THE ELDERBERRY (The Consultant) and {name} (The Client)

___________________________________________________________

The Consultant and the Client agree as follows:

SCOPE, TIME AND PLACE OF CONSULTATION:

Consultant will consult with Client concerning Client’s general health and health concerns and offer to develop formulations and/or compounds specifically designed to enhance Client’s general health and to meet Client’s specific health concerns.

FEES AND PAYMENT FOR SERVICE

For Consultant’s services Client agrees to pay Consultant $55.00 for the 30 minute session. Payment may be made to The Elderberry by check/cash/credit card. Formulations and/or compounds are not included in this fee.

CONFIDENTIALITY/ NON DISCLOSURE- CONSULTANT:

The Consultant agrees that it will not disclose, divulge, reveal, report or use, for any purpose, any confidential personal or business information of the Client which the Consultant has obtained, except as such information may be necessary or desirable to further the interests of the Client. This obligation will survive indefinitely upon the termination of this Agreement.

LIMITATION OF LIABILITY:

It is understood and agreed that the Consultant will have no liability to the Client, or any other party, for any loss or damage (whether direct, indirect, or consequential) which may arise from the provision from its services.

INDEMNIFICATION:

The Client will indemnify and hold the Consultant harmless from any claims against the Consultant by any other party, arising directly or indirectly out of any of the services rendered by Consultant for Client under the provisions of this Agreement. Consultant will give Client notice of any claim, or the commencement of any suit, action or proceeding with respect of which indemnity may be sought, and will give Client information concerning any claim as the Client may request. Consultant may, at Consultant’s expense, participate in or assume the defense of any suit, action or proceeding, provided that Consultant shall thereafter consult with Client upon Client’s request with respect to such suit, action or proceeding.

QUALITY OF SERVICES:

The services provided are not intended to diagnose or treat any medical condition or replace regular healthcare services.
I understand and agree with the above
Date

MonthDayYear
Date
Should be Empty:

Mini Consult Intake Form

Agreement for Consultation and Formulation Services