Aromatherapy Consultation Form

Aromatherapy Consultation Form
Name

First NameLast Name
Email
example@example.com
Partner status:
# of children:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Phone Number
Please enter a valid phone number.
How would you describe your health?
What do you expect Essential Oils can do for your well-being? What would like to change or improve for your health/wellness?
Do you have any current illness? If yes, what type of condition, for how long do you have?
What type of treatment(s) have your tried? What ha helped?
Are you under care of physician? Please list medications you are taking.
Please list any oils/aroma you dislike or have allergies.
Is there a possibility of our being pregnant now?
How much per day do you use of the following?

Coffee, Black Tea, Soft DrinksAlcoholCigarettes, cigars, TobaccoOther drugs

Informed Consent

I understand that this consultation is designed to gather information so that the practitioner is able to design and create aromatic products based upon my individual needs and for the express purpose of supporting health and well-being through lifestyle changes, health habits, and healthy mental well-being.

I understand that my aromatherapy practitioner Fabiana Henderson does not diagnose, prevent or treat any illness, disease, or any other physical or mental condition. I understand that I am consulting this practitioner for educational purposes only, of my own free will.

I understand that this treatment is not a substitute for medical treatments and it is recommended that I see a qualified professional for any physical or mental condition that I may have. I understand that any evaluation cannot determine a specific disease condition I may have, and that it does not replace the diagnostic services offered by licensed physicians.

I understand that Fabiana Henderson and/or their representatives will not suggest that I cease medical care I am undertaking. I understand that the decisions I make regarding my health care are my sole responsibility and I will not hold Fabiana Henderson or his/her representatives responsible for the consequences of my decisions.

I understand that Fabiana Henderson neither claims, nor implies, that any instruction, advice, counsel, suggestions, recommendations, services, or products he/she or his/her representatives provide, whether in person or by mail or by telephone, will cure, treat, prevent, or mitigate any disease condition; but are provided solely for the purpose of supporting the natural function of the body systems, and to improve general health and well-being.

I have read the above information and I hereby give my permission for Fabiana Henderson to design an aromatic program for me based upon my unique needs and goals
Date

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