Please make a copy of this form and fill out and email to firstname.lastname@example.org after you have purchased a consultation. Please note that per the FDA no claim is being made that I nor herbs or alternative therapies diagnose, treat, cure or prevent any disease. I also make no claim to be a licensed doctor, veterinarian or other licensed medical professional, but will educate in traditional uses of herbs and alternative products and therapies which is allowed under the Ninth Amendment. Your submittal of this form implies you are accepting and consenting to alternative educational services and the following clause required for service provision. “Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Katherine A Drovdahl, her family, agents, heirs and businesses including but not limited to Fir Meadow LLC from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s) including current, previous, and any subsequent communications on this or other wellness topics on any creature or human. It is the purchaser's responsibility to be sure that educational & herbal suggestions are cleared as allowable for use with regulatory authorities in the case of competing human or animal athletes engaged in competition. It is the purchaser's responsibility to research & be aware of any possible or potential drug - herb interactions or contraindications with their doctor, veterinarian, pharmacist or other licensed drug specialist. ” If any of these statements are disallowed by the current rule of law then the remaining statements shall still be in full force and the document remain intact. Only 1 major or 2 minor conditions per creature/human/herd will be covered per consultation. Price includes 1 - 2 short emails if clarification is needed within 1 business day of receiving your educational session/email. Followups available at reduced costs for the same creature/human/herd issue. Purchaser Name:_______________________________ Date:__________________________ Phone # to call:______________________OR Email to use:___________________________ Consultee Name:________________________ConsulteeSpecies:_______________________ Breed:____________________ AGE:________ Height:___________ Weight:_____________ Sex:____________Pregnant?___________ Lactating?_________ fixed/altered?___________ Health conditions (past/present):___________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________ Current diet/frequency/supplements_______________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Drinking water (well,city, softener, RO, other)__________________________________________________________________________
Concern/s wanted to cover: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Your purchase of any service or product from Fir Meadow LLC implies your acceptance of all statements on this consultation Intake Form Including all disclaimers at the top of the form. Your signature implies that you have read and accept all pages of this form including the disclaimer.