Hi There 👋
It's Paula. Thanks for your interest in our bespoke aromatherapy products, please fill out the form below and I will get creating.
Name of recipient
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First Name
Last Name
What type of product are you after? ie massage blend, inhaler, rollerball
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Phone Number
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Don't worry about the weird formatting when you type your phone number, any mobile number will work here :)
Format: (000) 000-0000.
E-mail
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
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Month
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Day
Year
Date
Medical History
Do you have any medical health conditions?
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Do you suffer with any of these?
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Cancer
Heart Conditions
Asthma
Diabetes (Type 1 or 2)
Low Blood Pressure
High Blood Pressure
Epilepsy
Other
Are you on any medication, if so, please list.
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Do you have any skin conditions?
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In your own words, could you describe the emotional and/or physical aspects of support you'd like this custom product to offer?
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Can you share with me the status of your current stress levels?
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Do you have any favourite aromatherapy scents or strong dislikes when it comes to essential oils?
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Are you presently expecting, attempting to become pregnant, recently welcomed a new baby, or breastfeeding? If relevant, kindly provide the due date and/or your baby's age so I can guarantee the safety of the oils used.
Do you have any allergies?
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What are your primary goals for using aromatherapy during labour? (e.g., relaxation, pain relief, emotional support)
Anything else you think I should know?
Disclaimer:
I can confirm that the details I've provided are accurate. I also agree to keep Paula Kemp informed of any changes to my health or circumstances while using my personalised aromatherapy product. I won't allow anyone else to use my products. Kindly sign below and add the date to confirm.
Signature
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Date
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Day
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Month
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Date
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