Healthcare Cats Claw Form

Healthcare Cats Claw Form

This form documents informed consent and authorization for the recommended therapeutic use of Cat's Claw (Uncaria tomentosa) as an herbal intervention. Practitioner or Clinic:

Patient Information

Insurance & Primary Provider

Medical History

Are you currently pregnant, breastfeeding, or planning pregnancy? Yes No

Are you currently immunosuppressed or taking immunosuppressive medication? Yes No

Are you taking anticoagulant or antiplatelet medications (e.g., warfarin, clopidogrel)? Yes No

Proposed Herbal Therapy: Cat's Claw

Indication for therapy:

Risks, Benefits, Alternatives & Acknowledgment

I acknowledge that the practitioner has explained the nature and purpose of Cat's Claw therapy, including expected benefits and reasonable alternatives such as conventional medical therapies, no treatment, or other complementary options. I understand that results cannot be guaranteed.

I understand potential risks and side effects may include gastrointestinal upset, allergic reaction, interaction with immunosuppressive therapies or anticoagulants, and other adverse effects. Serious adverse reactions are uncommon but may require medical attention.

I have been informed of alternative treatments, and I have had the opportunity to ask questions, which have been answered to my satisfaction.

Patient acknowledges receiving pre-treatment instructions and agrees to notify the practitioner of any new medications, supplements, or health changes before subsequent doses.

I acknowledge the following (check all that apply): Risks explained Alternatives discussed Opportunity to ask questions

Contraindications and Drug Interactions

It is the patient's responsibility to disclose all prescription medications, over-the-counter medicines, and dietary supplements. Cat's Claw may interact with medications affecting immune function or blood clotting. If you are on such medications, treatment should only proceed with the prescribing clinician's approval.

I confirm I have disclosed the following medications (if none, write "None"):

HIPAA / Privacy & Release Authorization

I acknowledge that I have received or been offered the facility's privacy practices notice describing how my protected health information may be used and disclosed. I authorize the release of medical information necessary for treatment, payment, or healthcare operations and for coordination of care related to this therapy.

Authorization to use and disclose protected health information for the purposes described above expires on:

I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

Voluntary Consent

By signing below, I consent to receive Cat's Claw therapy as described above. I understand that I may withdraw consent at any time and that withdrawal will not affect my right to future care or treatment.

Consent selection: I consent to the proposed Cat's Claw therapy. I decline Cat's Claw therapy at this time.

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