Page 5 – Classical herbal Consent & Voluntary Use Statement (Sign here) ---

Classical Herbal Medicine Informed Consent & Voluntary Use Statement

Description: Classical herbal formulas are potent and require accurate
diagnosis. Herbs are custom-ordered for your condition.

 

Main Risks & Side Effects

•  Common: GI discomfort, diarrhea, dry mouth, mild dizziness

•  Less common: allergy (rash, itching)

•  Rare but possible: temporary worsening of symptoms, effects on
live/kidney function

Situations Generally Not Recommended

•  Extreme weakness

• Severe liver or kidney dysfunction

•  Pregnancy or breastfeeding

•  Multiple chronic diseases with many prescription drugs

 

Patient Responsibilities

•  I have truthfully disclosed all medications, supplements,
allergies, and health conditions.

•  If any discomfort occurs, I will immediately stop use and inform
the practitioner.

•  Herbs are custom-ordered. Once confirmed and paid, no refund.

Voluntary Use Statement

[√] I fully understand the scope, risks, and contraindications of
classical herbal medicine.

[√] After the practitioner’s assessment, I voluntarily choose to use
classical herbal medicine.

[√] I will not hold the practitioner responsible for consequences
resulting from my failure to truthfully disclose my health status.

Patient signature: _____________________ | Date: _______________________

Practitioner signature: _______________________