Aromatherapy Intake and Consent Form

Aromatherapy is a complementary therapy that uses essential oils from plants and flowers. Aromatherapy and essential oils have a positive effect on the body. They aim to improve well-being and reduce stress.Aromatherapy is designed to effect the whole body, rather than targeting the symptom or disease. It assists the body’s natural abilities, helping to maintain balance, repair and recover.

Do you have sensitive skin? If so, please list any issues you experience.

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Do you have any allergies or sensitivities to oils, lotions, scents, foods, medicine, plants, etc?
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Are you currently pregnant or breastfeeding?    YES    NO

 Do you have Asthma?     YES    NO

Aroma Questions

Have you used therapeutic essential oils before?  YES      NO 

Which essential oils?  __________________________________________________________________

Are there particular scents or aromas that disturb you?

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Please indicate your LIKES / DISLIKES for each fragrance category: 
~ FLORAL  YES      NO                              ~ CITRUS  YES      NO    
~ EARTHY  YES      NO                              ~ SPICY  YES      NO   
                             ~ WOODSY  YES      NO

 I acknowledge and confirm that:

•  I understand Aromatherapy is not regulated by the Food & Drug Administration. 
• I understand that no guarantees are made regarding the results from Aromatherapy 
• 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 may irritate the skin if not stored or used properly
•  Essential Oils must not be used with animals
•  Essential Oils must not be used on the skin of babies or children under 1 years old 
• Essential Oils must be used with extreme caution for children under 5 years old.

I understand that essential oils and aromatherapy is a 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 on the 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. 

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