Custom Aromatherapy Intake form
It is important to get as much health history as possible in guiding clients on which essential oils may benefit them.
Please answer the questionnaire as honestly and accurately as possible, as it enables me to better serve you and formulate a blend and/or protocol specifically for you and your needs.

The aim of the questionnaire is to identify physical and emotional triggers of ill health and to explore the potential root cause(s) of your symptoms. Each blend is developed to meet each client's needs. Hazel Moon Botanicals reserves the right to integrate any custom blends into our Aromatherapy line-up if we feel it may benefit other clients. Essential oils and carrier oils will be selected based on established scientific evidence as well as energetic profiles.

Essential oils and carrier oils may be modified for your fragrance preferences and any disclosed allergies. Aromatherapy protocols (inhalation, massage oils, roll-on, salve, etc.) will be created with your lifestyle in mind.
All information gathered in this intake form is private and confidential.

Email address *
Consent and Liability Release. Please check each box in acknowledgement that you have read each condition and agree to the terms. *
By signing below, I hereby state that, to the best of my knowledge, this intake form contains true, complete and correct information. The undersigned hereby releases and agrees to indemnify and hold harmless Marie Davis/Hazel Moon Botanicals, LLC from all claims of injuries, damages, losses, death, costs, and expenses of all kinds, including legal fees, in any way arising from or related to therapeutic interventions received at any time from Marie Davis/Hazel Moon Botanicals, LLC. 
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Notice of Information Practices and Privacy Statement (HIPAA Privacy Policy) *
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