Please complete this form if you are interested in a custom essential oil blend designed specifically for you or your animal.

MM/DD/YYYY

Client Type

Medical History

Please describe all allergies in detail whether to medication, food, perfumes, etc. Type n/a if there are no known allergies.
Please describe all medications, supplements, and herbs in detail. Type n/a if not applicable.
Please list any long-term health concerns, including past surgeries.
Please list any concerns you or your pet are currently experiencing.

Aromatherapy

For example floral, herbal, spice, etc.

Client Goals

Consent

Please read and sign:

I have stated all my known conditions and have answered all the questions honestly.

I take it upon myself to keep the practitioner updated on my health.

I understand that the consultant does not diagnose, prevent, or treat illness, disease, or any other physical or mental condition.

I understand that this treatment is not a substitute for medical treatments or diagnosis, and it is recommended that to see a qualified professional for any physical or mental condition that I may have.

I understand that this treatment is not a substitute for medical care.

I understand the following:
• I am not being advised to take any essential oil products internally
• I must keep all essential oil products out of the reach of children
• Essential oils could be poisonous if swallowed
• Essential oils must be stored in a cool, dark place
• Essential oils may irritate the skin if not stored or used properly
• Essential Oils must not be used with animals unless created for them specifically.
• Essential Oils must not be used on the skin of babies or children under 1 year old
• Essential Oils must be used with extreme caution for children under 5 years old.

I hold my essential oil consultant harmless for any injuries or negative effects I may experience as a result of using the products I receive from this consultation.

I have read the above information, and I hereby give my permission to design an aromatic program for me based upon my unique needs and goals. I understand that essential oils and aromatherapy are complementary, holistic therapy, and not intended to treat, diagnose, and/or cure any medical issues.


I affirm that I have answered all questions accurately and honestly. And realize the importance of notifying the practitioner of any changes that may affect my health profile and understand that there shall be no liability onthe practitioner’s part should I forget to do so. I know that I need to seek medical attention by a proper qualified health professional when appropriate. I understand that all my information is strictly confidential and maintained at all times. Upon request, I may give my permission to the practitioner to use my information in a case study and may request a copy of the case study if so desired. I appreciate the practitioner’s dedication to using the highest quality, therapeutic grade essential oils.
Please type your full name.