Herbal Consultation Form

Herbal Consultation Form
Name
Address

Address

Street Address Line 2

CityState / Province

ZIP Code
Date of Birth

MonthDayYear
Date
Phone No
Email
[email protected]
Allergies
Sensitivities
Medical Background
Surgeries
Area of Health and Herbs youd like to focus on
Medication you currently take
Do you consent to the collection and use of your data for herbal consultation purposes?
CLIENT CONFIDENTIALITY AND RELEASE ~ I understand Cantu

Customs is not a medical provider and this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions. As such, the practitioner does not prescribe medical treatment. I have stated all my known conditions and take it upon myself to keep the practitioner updated on my health. Confidentiality of medical and personal information obtained during the course of the practitioner's work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release from their client before taking any information about them. I give my permission to this practitioner take notes, including health history, medical and/or personal information. All information will remain private.

By writing your name below you acknowledge you have read the client confidentiality and release and that all information provided is accurate.
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