CONSENT TO HERBAL CONSULTATION AND SERVICES DISCLAMER Informed Consent and Disclosure Form This form is to define the conditions for both you the client and me the practitioner. With this form I will identify the purpose of the counseling and confirm your understanding of the terms of consent and my goals pertaining to your health and your desired information. The Role of the Counselor I have attained my Master Herbalist Certification from the School of Natural Healing in Springville Utah. This education involved prerequisites of, Family Herbalist, Herbalist, Nutritional Herbalist and Advanced Herbalist. I am schooled In Human Anatomy, Advanced Herbal Chemistry, Nutrition and Elimination, Herbal First Aid, Botanical Identification, Organic Horticulture, Herbal Preparations, Raw Food, Fasting Procedures, Proper dieting and other Natural Healing Therapies. As your educator it is my goal to partner with you in your goals of obtaining health and knowledge to eventually supply all of your own needs for an ability to be as healthy as you desire. It is my personal decision if I decide the client/counselor is no longer beneficial for either of us anymore, in which case I can refer you to another practitioner or stop future consultations. I invite you to question me about my schooling, life experiences, anything you are interested in and also encourage you to teach me. Opinions may be opposing and we must accept that not all subjects touched on can come to equal conclusions with the counselor and client. The overall eating lifestyle is of my concern, the proper food intake being mostly raw, plant based high nutrient per weight, high vibration foods (Examples: Fruits, Vegetables, Nuts, Grains, Seeds & Herbs)is essential to obtaining overall health and allowing the correct environment for your herbs and therapies to work, be absorbed and used. Unless the client takes responsibility for reducing mucus forming foods such as Meats, Dairy, Refined flours, Refined sugars, Alcohol or other unhealthy habits and increasing plant intake to agreed percentage you will not receive optimal results. It is my goal to partner with the client not control the client. Remember this, I do not diagnose, cure, prevent or treat diseases. I recommend that you partner with me as well as with your primary health physician for information. In addition, all information we discuss as well as client records are kept confidential unless I am subpoenaed, I will take this very seriously! Client Rights and Responsibilities Payment for your consultation or other service provided will be accepted prior to or after your appointment. I accept cash, money orders, checks, credit cards and PayPal. Please do not post date checks. Please, give a minimum of 24 hours notice for reschedule or cancelation of my services or you will be charged the flat fee of $25.00 for any missed appointment. It is the client’s responsibility to inform me of any adverse reactions from herbs or any other supplements ingested. As the client, you have the right to excellent care and respect! If you do not agree with a protocol I recommend please let me know! If you think we are not proper partnerships just let me know. If you acquire another practitioner you may request to have my client information for you disclosed to them. Herbal Safety Guidelines Side effects The historical record and modern research indicate that the herbs most often used for healthcare have an exceptional safety record. However, adverse events can occur after using any active substance. Side effects that have occasionally been reported after using herbs include headaches, skin rashes and digestive upsets. Such effects generally resolve rapidly, especially if the dosage is reduced or the herb is stopped. Allergic reactions are also very rare but have been reported, usually in individuals with contact allergy to specific plants. As a Master Herbalist I may be able to propose certain measures to reduce any discomforts and may refer you to another licensed practitioner. Herb-drug interaction Although speculative interactions between herbs and drugs are sometimes publicized, confirmed cases are rare. Nevertheless, some prescribed drugs are very strong and have a narrow range of safe dosage, which makes any interaction more risky. It is the responsibility of the client to disclose fully any medications currently in use, including other herbs and supplements, so that they can be offered informed advice. Clients also are 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 any surgical procedure, and in the event of being prescribed anticoagulants, antiepileptic drugs, and digoxin until expert advice is received. Toxicity Client safety is paramount, and it is our business to stay current with the literature on herbal safety. We 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, and it will be important for the client to divulge any previous history of disease in either of these organs. Herbs also should not be used during pregnancy or lactation without expert advice, and clients who become pregnant should stop taking herbs until advice is received. I, ______________________________________, have read this document and I understand the nature and extent of the client-practitioner relationship. I herby voluntarily consent to an herbal consultation. I understand that I am free to discontinue service at any time. I understand that Jason Kvestad is not a licensed physician and cannot diagnose or treat disease, or prescribe drugs. I understand that an herbal consultation is not a substitute for regular medical care. If I have not already done so, I agree to consult a doctor for any serious or life-threatening disease condition, either for myself or someone under my guardianship. I am aware that I have not received any guarantee of outcomes or success that I will receive from services by Jason Kvestad. Print Name: ________________________________________ Signature: _________________________________________ Date: ______________ Parent/or Guardian Print Name: ___________________________________ Date: _____________ Parent/or Guardian Signature: ____________________________________ Date: _____________ Practitioner Print name: _____________________________________ Practitioner Signature: ____________________________________ Date: ___________ Page 1 of 2 Jason Kvestad MH www.herbalhealtheducation.com Master Herbalist 507-581-4227 Herb and Health Educational Counselor