Disclaimer & Consent to Services
Olympia Free Herbal Clinic
The Security Building
Suite 401, 203 4th Ave, Olympia, WA 98501
(360) 753-1293
1.
Disclaimer:
Let it be known that the practitioners, staff, and volunteers of the Olympia Free Herbal Clinic
are not licensed to diagnose, treat, cure or prevent any disease. The practitioners, staff, and
volunteers are not licensed physical therapists, massage therapists, chiropractors, registered
dietitians or medical doctors unless otherwise specified. Clients of the Olympia Free Herbal
Clinic should be advised that we do not offer any professional medical or psychological care
or advice, and that all clients are ultimately responsible for their own health care.
2.
Herbal Disclaimer:
Adverse events can occur after using any active substance. Side effects that have occasionally
been reported after using herbal medicines include headache, skin rashes, and digestive
upsets. Such effects generally resolve rapidly, especially if dosage is reduced or stopped.
Allergic reactions are very rare but have also been reported. Herbal medicines can have
adverse effects during pregnancy or lactation. In order to provide an accurate and safe health
consultation, it is strongly encouraged that clients let practitioners know if they are currently
pregnant or breastfeeding. It is the responsibility of the client to disclose fully, any
medications currently in use, including other herbs or supplements they are using, in order to
best prevent adverse interactions between herbal medicines and other substances. The kidneys
and liver are the organs most vulnerable to potent substances, and it is the responsibility of the
client to divulge any known history of disease in either of these organs. OFHC practitioners,
staff and volunteers will not expose clients to plant doses known to have toxic side effects.
Note: Many of the herbal medicines made available to Olympia Free Herbal Clinic clients contain
high percentages of grain alcohol, which can cause stress on the liver and other organs. Alcoholfree medicines are also available upon request.
3.
Confidentiality:
All information provided by clients to the Olympia Free Herbal Clinic is completely
confidential. It will be available only to OFHC practitioners in provision of health
consultations. No information under any circumstances will be divulged to anyone else
without the explicit signed consent of the client.
I, _________________________ (print name), the undersigned, have read this document and I
understand the nature of the client-practitioner relationship. I hereby voluntarily consent to an herbal
health consultation. I understand that I am free to discontinue service at any time. I understand that
Olympia Free Herbal Clinic and its practitioners and volunteers are not licensed physicians and therefore
cannot diagnose or treat disease, or prescribe medication. 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 medical professional
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 or assurance of outcomes or success
from services provided by Olympia Free Herbal Clinic practitioners or volunteers.
Client Signature________________________________________
Date________________________