• Client Information Sheet

  • Current Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Client Type*
  • Format: (000) 000-0000.
  • Employment Status*
  • Any Surgeries*
  • Musculo-Skeletal
  • Reproductive System
  • Digestive
  • Circulatory & Respiratory
  • Skin
  • Nervous System
  • Other

  • Holistic Health Consultation Agreement

  • Agreement Between Herbalist and Client


    This agreement is made between Detox International, hereinafter referred to as “the Holistic Practitioner,” and {fullName}, hereinafter referred to as “the Client.”

  • 1. Disclaimer of Medical Advice and Limitations of Service

    • The Holistic Practitioner is a trained herbalist, not a licensed medical doctor, and does not diagnose, treat, or cure disease, nor prescribe pharmaceuticals or advise on discontinuation of prescribed medication.
    • The services provided are for educational purposes, focusing on traditional and historical uses of herbs, nutrition, and lifestyle practices for wellness support.
    • Information provided should not be considered a substitute for professional medical care and diagnosis.

    • Clients are responsible for their health and are advised to consult a qualified medical professional for diagnosis, treatment, and before starting any new herbal remedy, particularly if they have a known medical condition, are pregnant, or nursing.

  • 2. Informed consent and client responsibilities

    • The Client understands that all recommendations provided by the Holistic Practitioner are for their consideration and are not mandatory. The Client is free to follow or disregard any recommendations as they choose.
    • The Client agrees to fully disclose any current medications, herbs, or supplements they are taking to ensure the Herbalist has all relevant information.
    • The Client understands that results are not guaranteed and individual responses to herbs can vary.
    • The Client will immediately discontinue the use of any recommended herbs and notify the Holistic Practitioner if any unanticipated or unpleasant effects occur.
    • The Client will notify the Holistic Practitioner if they become pregnant or start a new medication.
    • The Client acknowledges the importance of educating themselves about any herbs they consume. 

  • 3. Assumption of risk and release of liability

    The Client assumes all risks associated with consultations and the use of recommendations, including potential side effects or interactions with medications. The Client releases the Holistic Practitioner and [Your Business Name, if applicable] from liability for any claims or damages related to the consultations or recommendations. The Client also agrees to indemnify the Holistic Practitioner and Detox International against any claims or losses. 

  • 4. Confidentiality

     Client records will be kept confidential in accordance with federal and state guidelines and will only be disclosed with written consent. 

  • Important Legal Notice (Louisiana Law)
    Under Louisiana Civil Code Article 2004, any clause that purports to exclude or limit liability in advance for physical injury, gross fault, or intentional acts is considered null and unenforceable as a matter of public policy.

    Disclaimer

    • The herbal products offered by Detox International have not been evaluated by the U.S. Food and Drug Administration (FDA). They are not intended to diagnose, treat, cure, or prevent any disease.
      Content provided is for educational purposes only, and not a substitute for professional medical advice.
    • Herbal remedies may interact with prescription medications or pose risks for individuals with certain health conditions.
      Consult a qualified healthcare provider before using any herbal product, especially if you are pregnant, nursing, taking medications, or have an existing medical condition.

  • 5. Acceptance of terms

     
    By signing, the Client confirms they have read, understood, and agreed to the terms of this agreement. 

     
    Client Name: {fullName}

    Date: {dateSigned}

     

     

    Holistic Practitioner Name: _______________________________________

    Holistic Practitioner Signature: ___________________________________

    Date: {currentDate}

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year

  • Electronically approved by Zachary Ramzey III
    The Holistic Practitioner, on behalf of Detox International

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: