Client Intake Form (Page 4 of 4) in pdf

What outcome are you looking for as a result of your consultation? ______________________________________

_____________________________________________________________________________________________

Please answer the above as honestly and accurately as possible, as it enables me to better serve your and create a

blend and/or protocol specifically for you and your needs. The aim of the questionnaire is to identify causes of ill

health and to assess the root cause of your dis-ease. Each blend is specific to each client's needs and not intended

to be shared by family members and friends. Protocols will be created with your lifestyle in mind.

All information gathered in this intake form is private and confidential.

I acknowledge and confirm that:



I am of legal age and I am requesting a consultation from Lora Cantele, R.A.



This consultation is for educational purposes and is not to diagnose or treat disease.



I understand this consultation is not intended to replace medical care and I will seek medical treatment

from a licensed health care provider, if required.



I understand botanicals (including essential oils) may be contraindicated with certain health conditions.

For this reason, I confirm that I have had a general physical exam from a medical doctor within the last 12

months and have disclosed any diagnosed conditions on the Client Information form.



I understand that botanicals (including essential oils) can interact with prescribed medication. For this

reason, I have disclosed all medications that I may be taking on the Client Information form.



I will notify any healthcare provider of any essential oils, herbs, and/or dietary supplements that I may be

taking.



I understand Aromatherapy is not regulated by the Food & Drug Administration.



I understand that no guarantees are made regarding the results from Aromatherapy or natural health

methods, and that achieving wellness requires my commitment to my own good health, whether through

diet, exercise or stress relief.



I am under no obligation to follow any recommendations for lifestyle changes made by Lora Cantele, R.A.

I understand Aromatherapy is not to be thought of as a cure for ailments, that Aromatherapy is a complementary

means used to assist the body in healing itself. Also, that Aromatherapy is not meant to take the place of diagnosis

or treatment by a qualified medical practitioner. I will seek medical treatment from a licensed healthcare provider if

required. By signing below, I hereby state that, to the best of my knowledge, this intake form contains true,

complete and correct information. The undersigned hereby releases and agrees to indemnify and hold harmless

Lora Cantele, R.A./Enhancements Aromatherapy LLC from all claims of injuries, damages, losses, death, costs, and

expenses of all kinds, including legal fees, in any way arising from or related to therapeutic interventions received

at any time from Lora Cantele, R.A./Enhancements Aromatherapy LLC.

_____________________________________________________________________________________________

Signature

Date

Please return to: or mail to the address below

Lora Cantele, R.A. c/o Enhancements Aromatherapy LLC

5435 Indian Summer Ct, Boulder CO 80301

Enhancements Aromatherapy LLC

Client Intake Form

Client Intake Form Page 4

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