Three Leaf Farm Herbal Equine Intake Form

 
Name *
Name
Date of Birth
Date of Birth
Phone
Phone
Checkbox *
By checking this box, I understand that the information contained herein will be confidential unless I expressly authorize release of this information. I understand that Sara Martinelli is a trained, Certified Herbalist, she does not have a medical degree and cannot diagnose medical conditions. I understand that she will be suggesting herbal treatment in addition to any health care protocol that has been suggested by my primary physician. I understand that this treatment does not replace traditional medical treatment and should not be undertaken without notifying my primary physician. I hereby release Sara Martinelli and Three Leaf Farm from any liability due to unforeseeable reaction to a specific herb or protocol.