Aromatherapy Client Consultation Form

Aromatherapy Client Consultation Form
Client Name
First NameLast Name
Age
Gender
Date of Birth
MonthDayYear
Date
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Civil Status
Employment
Height (cm)
Weight (kg)
Select an appointment
Reason for visit

Agreement
I completely understand how the science of aromatherapy works for my body. It is only a supporting holistic treatment that is not to intended treat or diagnoses any medical conditions and illnesses. I attest that all personal, medical information listed above is true and accurate, in the event that I am required to provide a medical certificate, I shall comply with submission. All information listed on this form is strictly confidential and privacy shall be maintained at all times. The practitioner can use my information for a case study, generation treatment plans, and my personal copy should be given to me 2 to 3 days prior to my first day of treatment. I should appreciate and respect the practitioner's recommendation of therapeutic treatments with their choice of highest grade essential oils and essence.
Client Signature
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Date Signed
MonthDayYear
Date
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Health Screening