I authorize the pharmacist(s) and herbal consultant(s) at this practice to review my medical and medication history for the purpose of providing medication therapy management and/or herbal consultation services.

I understand that information shared during this consultation is confidential and will be used solely for the purpose of improving my health outcomes. I acknowledge that herbal and integrative recommendations are complementary in nature and do not replace advice from my primary care team.

I consent to the secure electronic storage of this intake form and understand I may withdraw consent and request record deletion at any time by contacting this practice in writing.