Consultation Form | NC Aromatherapy

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Consultation Form

Please fill out the following form to determine eligibilty for the use of essential oils and any contra-indications.

First name

Last name

Email

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Have you had any surgery or cosmetic procedure in the lasr 6 months? If yes what was it?

Do you have any allergies?

Do you have diabetes?

Are you pregnant?

I declare that the info I’ve provided is accurate & complete

Initials

Your Signature

Thanks for submitting!

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