Aromatherapy Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently (or possibly may be) pregnant? *

Do any of the following apply to you? Please tick all that apply.

Hay fever Asthma Epilepsy High blood pressure Eczema Psoriasis

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Are you currently receiving other alternative treatments (e.g. Homeopathy, Acupuncture etc.)? *

Please specify: *

Have you had an Aromatherapy session before? *

How was your experience? *

How many previous sessions have you attended? *

Do you find time to relax or meditate? *

How often? *

Do you find time to exercise? *

How often? *

What type of exercise do you do? *

How many hours of sleep do you get in an average night? *

Please rate your quality of sleep (1 being the worst, 5 being the best): *

Please rate your level of stress: *

What would you like to get out of the session? *

Do you have any concerns you would like to discuss before the session? *

Please specify: *

Do you have any specific oils you would like to be used or avoided in the session? *

Please specify: *

Treatment Information

What is Aromatherapy?

Aromatherapy is a holistic healing treatment that uses natural plant extracts to promote health and well-being. Sometimes it’s called essential oil therapy. Aromatherapy uses aromatic essential oils medicinally to improve the health of the body, mind, and spirit. It enhances both physical and emotional health.

Aromatherapy is thought of as both an art and a science. Recently, aromatherapy has gained more recognition in the fields of science and medicine.

What are the benefits of Aromatherapy?

Aromatherapy has an array of benefits. It’s said to:

manage pain
improve sleep quality
reduce stress, agitation, and anxiety
soothe sore joints
treat headaches and migraines
alleviate side effects of chemotherapy
ease discomforts of labor
fight bacteria, virus, or fungus
improve digestion
improve hospice and palliative care
boost immunity

Remember that aromatherapy is meant to be a complementary therapy. It’s not meant to replace any doctor-approved treatment plan.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to the Aromatherapy treatment to be carried out.

Client Signature: *

Tap or click on the signature above to sign