Krista Dawn Poulton
Medical Herbalist
Treatment Consent Form
Krista Dawn Poulton is a qualified professional member of the Canadian Herbalist Association of BC
and the American Herbalist Guild. Krista Dawn Poulton has completed a 2130-hour Herbal Medicine
diploma program with Pacific Rim College in Victoria, BC, consisting of over 500 hours of practical
clinical training, over 500 hours of biomedical training, and roughly 1000 hours of therapeutic
herbalism including herbal, supplementation and nutritional training. Additionally she has completed
108 hours of mentorship in Traditional Chinese Energetics with Nadine Ijaz in 2012-2013.
Krista Dawn Poulton has trained as a general herbal practitioner and has integrated various energetic
and medical diagnostic modalities within her practice. She has focused her training on women’s health
and family care through continuing education and mentoring with other practitioners within this area of
specialty.
A Medical Herbalist Consultation includes patient history, physical exams and any relevant
laboratory tests. Initial consultation appointments may last 60-90 minutes, with follow-up
appointments ranging from 30-45 minutes. The outcome of the consultation is a personalized treatment
plan including Herbal Medicine, Holistic Nutritional Counseling and Lifestyle Counseling guiding the
patient to optimal health.
You are not required to take the products, however, if you choose to, you should follow the
recommendations given regarding dosage and preparation requirements to avoid complications
and to promote efficacy of the treatment.
Herbal Medicine utilizes the seed, root, leaf, bark or flower of a plant in tincture, tea, powder, capsule,
infused oil or cream form to support people on their healing journey. In herbal medicine herbalists use
the whole plant, which is comprised of complex phytochemicals that interact in synergy with the
human body, which produce a beneficial therapeutic effect. Herbal medicine is not only utilized when
an individual is unwell but is also used to tone the organs and systems, to provide stress relief, adapt
the body to various environment situations, as well as increase the body's immune system. Therefore
herbal medicine is used for the treatment and prevention of disease as well as maintenance of health.
Herbal medicine addresses the root of the imbalance in an individual, as well as providing symptom
relief. The goal is to stimulate the individual’s innate healing power by teaching the body how to heal
and how to defend itself. Therefore the goal of herbal medicine is not to prescribe an herb for an
indefinite amount of time but to increase the body's own ability to thrive.
Although Herbal Medicine is deemed a safe and effective treatment for a variety of health
conditions there is a risk of adverse reactions to herbal medicine including and not limited to
headaches, nausea, and digestive discomfort. Typically, these side effects can be seen as a healing
reaction if under a week duration. However, it is advised that you discontinue use of the
treatment and phone Krista Dawn Poulton immediately if you experience any adverse reactions.
Krista Dawn Poulton checks herb and pharmaceutical interactions but she is not liable for new
herb-drug interactions that have not been cited or sourced. Please disclose ALL pharmaceutical
and supplements that you are currently using.
Krista Dawn Poulton,
Victoria BC
Medical Herbalist
250-896-2291
Krista Dawn Poulton
Medical Herbalist
Holistic Nutritional Counseling will be utilized to help individuals with nutritional balancing, dietary
support, food allergies/intolerances, and weight management. Nutritional Counseling will include
whole food recommendations, cooking preparations, recipes, information regarding food
allergies/intolerances and supplemental recommendations. Krista Poulton will be providing relevant
literature in the form of handouts along with recommendations for recipe and lifestyle books.
Lifestyle Counseling and Stress Management will provide instructive strategies and techniques for
patients to make healthy lifestyle choices. These strategies will include stress reductions techniques,
exercise recommendations and suggestions for achieving optimal enjoyment of life through nature and
relationships.
Krista Dawn Poulton, Medical Herbalist will be utilizing a variety of diagnostic tools, not limited to
pulse & tongue diagnosis, laboratory testing and physical examinations.
It is the patient’s responsibility to disclose ALL pertinent findings from conventional medical
testing or other health care professionals. Krista Dawn Poulton does not replace the diagnosis
from a doctor, which in some cases is deemed important for the patient’s health.
Your information contained in the clinical practitioner’s file is confidential and will not be
reviewed by anyone else without your prior permission unless required by the law. Should you
wish to have the practitioner share information with another health care professional you will be
required to sign a release of information form.
I, _______________________________ have read and understood the above information. I
hereby give consent to treatment by the practitioner of this clinic.
____________________________________
Signature of Patient
____________________________________
Date
____________________________________
____________________________________
Signature of Witness
Date
If patient is under the age of 18:
____________________________________
Name of parent/guardian if applicable
____________________________________
Date
____________________________________
Signature of parent/guardian if applicable
____________________________________
Krista Dawn Poulton,
Victoria BC
Medical Herbalist
250-896-2291