Safety Intake Form – Animal Aromatherapy

As aromatherapy and the use of botanicals continue to gain acceptance within the holistic field, there is also increasing interest in incorporating aromatherapy and other natural therapies for use with our animal friends.

It is important to note that animal lovers always want what is best for their pets, and often will seek out information and advice via the internet, blogs and social media groups and for the most part the information may not include or contain safe use instructions, or applies to humans and not for actual use with animals.

Unfortunately, without education and proper instruction in the safe use of aromatherapy and botanicals for their animal friend the consumer is left to figure out how to use these ingredients on their own, or follow out-of-date or random advice. This may lead to the animal experiencing a negative reaction, yet the reaction is usually due to issues such as not diluting properly or accidental ingestion of large amounts), rather than when used safely with common sense use and with high-quality tested ingredients (vs artificial fragrances, oxidized or rancid oils, or cheap knock-off products, etc.)

If your animal friend has experienced a negative reaction due to exposure to essential oils or botanicals, please feel free to fill out and submit your information via the online Safety Intake Form below. Please submit one form per each individual animal.

Animal Aromatherapy Safety Intake Form

This form is for individuals that would like to submit details pertaining to a negative reaction that their animal friend may have experienced due to exposure or use of essential oils and or aromatherapy ingredients. The form must be filled out by the animal’s caregiver (owner) and include answers to all questions.

Submitted information will also serve as an educational tool to help others learn more about the safe use of aromatherapy with their animal friends. The information submitted will be compiled and shared with others (via published on blog, e-booklet, social media, website, etc.)

In order to submit a safety intake form the animal’s caregiver (owner) must answer all of the below questions (if a question does not apply, type in ‘does not apply’). We do not accept or process incomplete forms.

We encourage the submission of photos (if applicable), such as with a skin reaction. Photos must be properly labeled (Your Full Name, Animal’s Name and Date Taken).

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Submission Date*
MM slash DD slash YYYY
Reason for submitting a Safety Intake Form:*
Date of Incident and or Reaction:*
MM slash DD slash YYYY
Caregiver’s Name (First and Last)*
First Last
Contact Phone Number*
Email Address*
Address (Street, City, State, Zip code, Country)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Animal's Information
Animal’s Name*
Breed*
Sex*
- Male
- Female
Weight*
Age*
Please enter the age in years and/or months.

Essential Oil Questions
If you think the reaction may have been due to an essential oil or aromatherapy product please answer the following questions and be sure to include as much detail as possible.
If you are currently using essential oils, botanicals or aromatherapy products in your home or with your pet, please include those details.*
List the reaction/s experienced:*
Length of time between exposure to essential oil/s and reaction occurrence:*
Where were the essential oils/blends purchased from?*
List any and all essential oils (including both the common name and the botanical name i.e. Lavender (Lavandula angustifolia) if this information is provided on the product label).

Please also list aromatherapy company (list name), health food store, non-aromatherapy business (chain store, etc.), batch number, aromatherapist or other practitioner.
Were safety instructions given in regards to pertaining for use with animals?*
- Yes
- No
Which essential oil/s was the animal exposed to (please list all including the Brand Name):*
Date of purchase (list the date/s that the essential oils/ingredients were purchased):*
Were the essential oils diluted in a carrier base (vegetable oil, hydrosol, water-based ingredient, etc.) and if so list the type and amount used:*
What other ingredients/products was the animal exposed to (please list all, including Brand Name and date purchased):*
List the amount of essential oil used/consumed or exposed to. Include the amount of drops or size of bottle contents (if accidently consumed):*
What type of exposure (topical, internal, inhalation (via diffuser) (please list any and all and be specific re: if topical (how applied, how much, was it diluted, etc.), if inhalation (was it via exposure to a diffuser, if so, what type, how long, etc.), if internal (was it via drops to water dish, accidental ingestion, etc.).*
List the reaction (and symptoms) that you have noticed:*
How long did the reaction last (list amount of time (minutes, hour/s, day, week, etc.):*
What actions did you take to decrease the reaction (list detailed information (was the animal bathed and if so, what was used to bath the animal, etc.)*
Did you contact your veterinarian?*
- Yes
- No
What treatment was administered, outcome, etc. at the veterinarian's office?*
Were blood tests taken?*
- Yes
- No
What were the results of the blood test(s)?*
Did you contact the Animal Poison Control hotline?*
- Yes
- No
What instructions you were given by the Animal Poison Control hotline?*
Animal’s health status afterward (recovered, hospital stay, etc.):*
Animal’s current health status (include date if this form is being submitted a week or more after the reaction):*
Please use this area to list any additional information or details that you would like to share that are not listed via the general questions section:*

Form Submission Acknowledgement*
By submitting this online safety intake form you are acknowledging that all the information submitted is true and that you give permission for the information and details (including photos) to be compiled and shared with others and in other formats such as (published within a report, website, blog, social media, etc.).

You agree that this online form is not being submitted as a substitute or replacement for veterinarian medical care or emergency care for your animal. We have the right to reject any form submitted that is not complete or trustworthy. This online form option may be discontinued without any notice.
- I agree

Animal Aromatherapy Safety Intake Form

Step 1 of 5

Animal's Information

General Health Questions

Essential Oil Questions

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