Self-Medication Disclaimer

!Xam kwasi gi: xa

by Xam Bush Doctors

Healers and Herbalists • Practice No: 00012274/009

Personal Information

Name and Surname:

Date of Birth:

Email Address:

Diagnosis for Self-Medication

Please tick the condition(s) that apply to you:

Stress Insomnia Chronic Fatigue Hypertension Muscle Pain Relaxation Diabetes Sports Injury

Anxiety Spasms ADHD Cancer Other: ________________

Consent

I consent that !Xam kwasi gi: xa will be prescribing and administering medication to me. I also acknowledge and understand that any Registered Apprentice of the Traditional Practitioner on site, under the supervision of his Traditional Practitioner, will also be giving advice on Medication and prescribing medication under the Practice of Medicine. Traditional Medicines may have some risks. I understand that I have the right to ask about any of these risks and have any questions about my condition answered prior to treatment. I know it is up to me to inform the Traditional Practitioner/Staff of any Health Problems or Allergies I have, as well as Medication I am taking. I also agree that all information given about my Health to the Traditional Practitioner/Staff is truthful and for the best of my own well-being.

No Guarantees: I understand that the Practice of Traditional Medicines may not always have the desired results and that there is no Guarantee of Success. I understand that no contract, guarantee, warranty, or promise concerning the results of my Traditional Medication and/or Therapy services is made.