Questionnaire for bespoke products - Aromatherapy Shop

** NEW CUSTOMERS NEED TO FILL IN THIS FORM **

Order your custom made products here.

Please fill out the questionnaire with as much relevant information as you can. Every form is treated in complete confidence.

I will respond to your application via email as soon as possible.

Alison

Butterfly Dawn Aromatherapy

Butterfly Dawn Aromatherapy Consultation Form

Name::*
Email Address::*
What is the issue you would like help with?:*
Are you currently receiving treatment for said condition?:*
Are you on medication? Please indicate.:*
Have you any allergies?:*
General Health::
- Muscular/Skeletal issues eg Muscles, bones, joints
- Respiratory eg lungs, asthma, bronchitis
- Skin condition? eg eczema, psoriasis, rosacea
- High blood pressure
- Low blood pressure
- Anxiety, stress, depression
- Hormone imbalance, pmt, menopause
- Epilepsy
- Pregnant or recently given birth
- None of the above
More details on the above:*
Recent operations or injuries?:*
Essential Oils I like:*
Essential Oils I don't like:*
I have read the above information and I declare that the information I have given is current & correct. :*
I consent to details of my medical and treatment records being kept safely and securely for 6 years to meet GDPR and Insurance regulations:*
Would you like to be added to my Monthly Mailing List? By doing so you consent to receiving occasional emails about offers, treatments etc.:*
I agree that I have given you the above information to help you choose an aromatherapy blend for me. Please type your name and indicate yes or no.:*

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