Herbal Consults with Timothy

Client Intake Form

Please complete this form before your herbal consultation with Timothy. Everything you share is private and helps him prepare the right herbs, teas and plan for you.

About you

Full name *

Email *

Phone

Date of birth

What brings you in? *

Health information

Current medications & supplements

Allergies to herbs, plants or supplements

Please check if any apply to you

Please check anything that applies to you.

I am pregnant, there is a possibility of pregnancy, or I am nursingI have a gastro-intestinal flu, vomiting or diarrheaI have artificial joints, metal pins or silicone implantsI have heart disease, hypertension, hypotension, hyperthyroidism, hemophilia, diabetes, cancer, Parkinson's, lupus, adrenal suppression or multiple sclerosisI take prescription medication including beta blockers, diuretics or barbituratesI have allergies to plants or herbs (mugwort, motherwort, oregano, yarrow, lemongrass, rosemary or others)

Please read & acknowledge

I understand that Timothy Ruther is not a licensed physician, and that these services are not licensed by the state of Illinois. It is my responsibility to maintain a relationship with a medical doctor or other essential health professional if I so desire. I understand that Timothy Ruther is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies, and that these statements and services have not been evaluated by the US Food and Drug Administration. Herbal care, teas and supplements are not offered to diagnose illness.

I understand that methods may include vaginal steaming, Chinese and Western herbal medicine, and nutritional counseling; that herbs may need to be prepared and teas consumed according to the instructions provided; and that herbs may have an unpleasant smell or taste. I will immediately notify staff of any unanticipated or unpleasant effects.

I understand that while this form describes the major risks, other side effects may occur. Herbs and nutritional supplements are traditionally considered safe in the practice of Chinese and Western herbs, although some may be toxic in large doses, and some may be inappropriate during pregnancy. Possible side effects include nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify staff if I am or become pregnant. I understand that results are not guaranteed.

Any herbs or substances I add to the original blend myself are used at my own risk, and I do not hold Ahava Bey, Timothy Ruther, The Holistic Womb, or Zion Wellness Center liable for any negligence of any kind. I hereby release, waive and forever discharge The Holistic Womb, Zion Wellness Center, Ahava Kherut Bey and Timothy Ruther, and any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit, action, demand or right to compensation for damages arising out of my own acts or omissions or the recommendations given or any booked sessions. This agreement binds my heirs, executors, personal representatives, successors, assigns and agents.

I understand this is wellness support, not medical care, and not a substitute for a physician. *I understand the possible risks and side effects described above. *I have read and agree to the release and waiver above. *

Signature (type your full name) *