Natural Products Form

Nature To Nurture Natural Bespoke Products

'It's All About You'
These questions are asked for your own health & safety as all my products are bespoke & tailor-made for you. They also allow me to make better choices with regards to Aromatherapy & essential oils, which have safety indications. The information given will be treated as private and confidential under GDPR regulations and will not be revealed to any third party without your prior authorisation in writing. Please fill in as much as possible.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Town/CityCounty

Postcode
Phone Number*

Area CodePhone Number
Email*
example@example.com
What is your reason for requesting Natural Products? e.g. gift, would like help with Hayfever support etc*
Are you currently taking any medication?*

YesNo
If yes, please list e.g. steroids, anti-coagulants, HRT, blood pressure, antidepressants etc
Do you have any allergies?*

YesNoNot Sure
If yes, please list here e.g. nuts, wheat, grasses etc
This list is not exhaustive, if you have a condition not listed here please detail in the box below. Please tick the conditions that apply to you and circle if you know the specific diagnosis, please give any further detail in the box below:*

Arthritis - Osteo/Rheumatoid/OtherAnxiety/Panic AttacksCancerChronic Fatigue/ME/OtherCovid/Long CovidDepressionDiabetesDigestive Conditions - Crohns/Colitis/Diverticulitis/IBS/OtherEndometriosis/PCOD/PCOS/OtherEpilepsyFibromyalgiaFluid Retention/OedemaHeart ConditionsHeadaches/MigrainesHigh/Low Blood PressureHigh CholesterolHormonal Problems/EndocrineInsomnia/Sleep IssuesKidney/Bladder/Urogenital conditionsMenstruation Problems/Menopausal issuesOsteoporosisOther Pain/Inflammation (please detail below)Pregnancy (how many weeks)Respiratory - Asthma/COPD etcRheumatismSkin conditions – Dermatitis/Ezcema/Psoriasis (please detail below)Stress/Stress related conditionsThrombosis/PhlebitisThyroid - Overactive/UnderactiveVaricose Veins/Circulation IssuesNone/I don't have any
Please give any further information about conditions above or any other disorders/conditions/symptoms not mentioned above that may affect natural products used:
Anything else that might be important?
Consent for purchase of Aromatherapy Products for Yourself (please type your name)
Consent for purchase of Aromatherapy Products for A Child (please type your name if a parent or guardian)
Should be Empty:

Nature To Nurture Natural Bespoke Products