Aromatherapy Intake Form (Page 4 of 4) in pdf

Aromatherapy Intake Form Page 4

Aromatherapy Intake Form

Please read and sign:

I have stated all my known conditions and have answered all questions honestly. I take it upon myself to keep the practitioner updated

on my health.

I understand that the consultant does not diagnose, prevent or treat illness, disease or any other physical or mental conditions.

I understand that this treatment is not a substitute for medical treatments and/or diagnosis, and it is recommended that I see a qualified

professional for any physical or mental condition that I may have.

I understand this treatment is not a substitute for medical care.

I have read the “Safety Information Page” and agree to follow of these guidelines.

I understand the following:

I am not being advised to take any essential oil products internally

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I must keep all essential oil products out of the reach of children

•

Essential oils could be poisonous if swallowed

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Essential oils must be stored in a cool, dark place

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Essential oils may irritate the skin if not stored or used properly

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Essential Oils must not be used with animals

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Essential Oils must not be used on the skin of babies or children under 1 years old

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Essential Oils must be used with extreme caution for children under 5 years old.

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I hold my essential oil consultant, Jody Pesapane harmless for any injuries or negative effects I may experience as a result of using the

products I receive from this consultation.

I hold Mindful Mixtures harmless for any injuries or negative effects I may experience as a result of using the products I receive from

this consultation.

Client Signature

Date

Aromatherapy Intake Form Page 4