Name *

First Name

Last Name

Phone

(###)

###

####

Medical background *

Do you have any of the following?

Heart condition

High / low blood pressure

Epilepsy

Diabetes

Skin conditions (eczema, psoriasis, etc)

Respiratory conditions (asthma, COPD)

Recent surgeries or injuries

Other (please specify below)

Are you currently pregnant?

Do you have any allergies?

Are you currently suffering from an infection? (cold, flu, Covid, etc)

None of the above

Have you received holistic treatments before?

Yes

No

If yes, please tell me

What would you most like to achieve from your session today?

Relaxation and stress relief

Better sleep

Pain of tension relief

Emotional balance

Energy boost

Other

Aromatherapy choices

Please tell us what types of scent you like:

Floral (geranium, rose)

Herbal (lavender, rosemary)

Citrus (orange, grapefruit)

Grasses (lemongrass, vetiver)

Spice (black pepper, ginger)

Musk / exotic (frankincense, myrrh)

Woody (juniper, sandalwood)

Signature / name *

Please type your name

First Name

Last Name

Date

MM

DD

YYYY