General - Nutritional Supplement Informed Consent

Nutritional Supplement Recommendation Consent

Nutritional supplements (including vitamins, minerals, enzymes, amino acids, herbs, and other botanical extracts) may be recommended as part of your health protocol. These products are recommended to support your physiological processes and optimize nutritional status.

Unlike prescription drugs, nutritional supplements are classified as foods and dietary support. They are not intended to diagnose, treat, cure, or prevent any disease. Any suggestion of their use is for general health maintenance and support.

Potential risks of supplement use include mild digestive upset, allergic reactions, or interactions with prescription medications. It is your responsibility to consult with your prescribing physician regarding any changes to your medication schedule or potential interactions.

Patient Safety Information

Are you currently pregnant, planning to become pregnant, or nursing/breastfeeding? * Required

Have you ever experienced an adverse or allergic reaction to a vitamin, mineral, herb, or supplement? * Required

Yes No

If yes, please list the supplement(s) and describe the reaction you experienced: Optional

Please review and acknowledge the following statements: * Required

I understand that nutritional supplements are not a substitute for medical treatment or drugs.I agree to fully disclose all current medications, health conditions, and pregnancy status.I understand that natural products carry potential risks of side effects or drug interactions.I understand that I am under no obligation to purchase supplements through this practice.

Patient Attestation & Consent Signature * Required

Signature

By signing below, I acknowledge that I have read this document, understand the difference between nutritional supplements and medical treatments, and consent to the nutritional supplement recommendations made as part of my care plan.

General - Nutritional Supplement Informed Consent

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