Injury Reports
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First Name
Last Name
Email address *
Who were the essential oils used on? State age and gender (if known): *
What essential oils were used (list all individual and blends): *
How were they used (oral ingestion, topically, bath, diffusion, etc): *
Were the essential oils diluted or used undiluted (neat application, then diluted) *
What was the percentage of essential oil used (how many drops, ounces, etc. if known):
How many applications:
Essential oil brand (if known):
Was the oil over 6 mos. old:
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What was the experience during (symptoms, general feelings of discomfort, adverse reactions): *
What was the experience immediately afterwards:
What was the experience sometime later (how much time /days passed):
Describe if any medical intervention (blood tests, other tests, etc.; include name of hospital/clinic/Dr, day of exam/tests):
What type of essential oil session did you receive (massage, nursing, spa, etc):
Dates of essential oil application/s (if known):
Personal Testimonial Page (please use this space for additional details that you would like to share to make your experience more clear):
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This form was created inside of Atlantic Institute of Aromatherapy.