Client Consultation Form

Client Consultation Form

Pleae complete and submit before your appointment
Full Name *

First Name Last Name
Email
example@example.com
Phone Number
Please choose your Appointment option:

Phone Zoom
Reason/Focus for the Consultation:
On a scale of 1 - 10, where 10 is the worst, what is the severity?
Check any possible contraindications or areas of concern *

Allergies Diabetes Epilepsy Hypotension Hypertension Pregnancy Thyroid Problems Varicose Veins/Thrombosis None Other
More information on contraindication or area of concern.
Are you currently taking any medication?

Yes No
If yes what medication?
Have you had surgery that currently has an impact on your health: emotional or physical?

Yes No
If yes what and how recent?
Have you been in an Accident that currently has an impact on your health: emotional or physical?

Yes No
If yes what and when?
Describe your General Health
Describe your Energy Levels
Describe your Stress Levels
What is your skin condition

Normal Sensitive Dry Oily Sensitive
Physical Challenges

Headaches Sleep disturbances & quality of sleep Skeletal problems ( back/spine, legs, arms/shoulders, other) Joint problems (arthritis, aches and pains, sciatica, chilblains, odema, rheumatism, other) Respiratory complaints (asthma, breathing difficulties, bronchitis, throat infection, sinusitis, colds, flu, other) Digestive complaints (constipation, indigestion, colitis, candida, other) Urinary complaints (Cystitis, thrush, fluid retention, other) Menstrual problems, PMS, Menopause Skin complaints (allergies, dermatitis, eczema, psoriasis, other) None
Provide more information on the condition here
Emotional Challenges

Stress/Anziety (depression, headaches, migraines, insomnia, tension, other) Emotional concerns None
Any Additional Information you would like to share?
DISCLAIMER: As a professional Aromatherapist, I do not make any claim of replacing any holistic or medical therapy. I do not advise clients in any form that my treatment is superior to any other holistic or medical one, as my therapy is of a complementary nature ONLY, rather than a curative treatment in itself.

It is not within my Scope of Practice to advise on ANY internal applications of the essential oils.
Please choose your preferred Method of Payment so I can send you the relevant Invoice at the end of the Consultation.

PayPal Stripe E-Transfer
Date

Month Day Year
Date
Client Signature

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