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You are here: Home / Health History Intake Form for Aromatherapy Consultations

Health History Intake Form for Aromatherapy Consultations

Thank you for purchasing an Aromatherapy Consultation!

Consultation can be done via SKYPE call or in-person at our center.

NOTE: Before you schedule a SKYPE call with us, you must first fill out the Health History Intake Form for your animal.

Health History Intake Form:

Step 1 of 6

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  • Your order number can be found on the email receipt that was sent to you by [email protected] (not PayPal's invoice number).

    It looks like this:
  • You can either download the Health History form in Word/PDF format and then upload your completed intake to this form, or you can utilize the online form. Please choose from the following:
Save and Continue Later
  • You can download whatever format you would prefer to fill out the form:
    Word Document
    PDF
    Once you have completed the form, please save the completed form to your computer for reference and upload it using the upload feature below.
    Accepted file types: doc, docx, pdf, Max. file size: 2 MB.
Save and Continue Later
  • Online Health History Intake Form

  • MM slash DD slash YYYY
  • Caregiver's Information

  • If you do not have the full address, please simply list the City and State.
  • Animal's Information

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  • Health Information

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  • Disclaimer Acknowledgment:

    The information shared during the consultation evaluation is for personal education awareness only, it is not meant to diagnose or treat any serious health problems/conditions. I will agree to keep the practitioner updated on any new health issues and do not hold the practitioner responsible or liable for any health conditions/concerns that were not disclosed. I will use Aromatherapy in a safe manner, for topical and inhalation use only. I am aware that all essential oils and products should be kept out of reach of children and animals.
  • MM slash DD slash YYYY
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  • You're almost done!

    You're ready to submit your form.
    You will receive email confirmation with the form fields you submitted.
  • This field is for validation purposes and should be left unchanged.
Save and Continue Later

 

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Disclaimer: The information contained in the educational programs and course materials are not intended to diagnose or take the place of professional health care. Always consult with a veterinarian physician in regards to any serious health concerns and issues. The information contained in this handout is for personal awareness only, it is not meant to diagnose or treat any serious health problems/conditions.

Ashi Therapy Ashi Aromatics Inc. © Copyright: Ashi Therapy Ashi Aromatics Inc. All rights reserved.

No part of this document or information may be copied, transmitted, shared or sold.

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