Minor Client Consent Form

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Minors are permitted to receive aromatherapy services from Ampersand Essentials Aromatherapy LLC. A parent or legal guardian must be present during all consultations and appointments, and must sign this personal client consent form, along with the minor (if possible).

Guidelines

1) Minors (all clients under the age of 18) can only receive aromatherapy services with written parental/legal guardian consent

2) In collaboration with the consenting adult and child, the aromatherapist will assist in establishing goals for the services and appointments

INITIAL HERE *

For clients age 16-17 if both the client and the parent/guardian are comfortable with the minor attending all appointments by themselves; otherwise the parent/guardian should attend all consultations and appointments.

Reminders on Consent

All known conditions have been stated and all questions have been answered honestly. The client and parent/guardian take it upon themselves to keep the practitioner updated on their health.

The client and parent/guardian understand that the practitioner does not diagnose, prevent or treat illness, disease or any other physical or mental conditions.

The client and parent/guardian understand that this treatment is not a substitute for medical treatment and/or diagnosis, and it is recommended that they see a qualified professional for any physical or mental condition they may have.

The client and parent/guardian understand this treatment is not a substitute for medical care.

The client and parent/guardian understand the following:
• They are not being advised to take any essential oil products internally, unless otherwise specified
• They must keep all essential oil products out of the reach of children, unless otherwise specified
• Essential oils could be poisonous if swallowed
• Essential oils must be stored in a cool, dark place
• Essential oils may irritate the skin if not stored or used properly
• Essential oils must not be used with animals
• Essential oils must not be used on the skin of babies or children under 1 year old
• Essential oils must be used with extreme caution for children under 5 years old

The client and parent/guardian hold Ampersand Essentials Aromatherapy LLC harmless for any injuries or negative effects they may experience as a result of using the products they receive from any consultation or appointment.

The client and parent/guardian have read the above information and hereby give their permission to design an aromatic program for them based upon their unique needs and goals. They understand that essential oils and aromatherapy is a complementary holistic therapy and is not intended to treat, diagnose, and/or cure any medical issues.

The client and parent/guardian understand that all of their information is strictly confidential and maintained at all times. Upon request, they may give their permission to Ampersand Essentials Aromatherapy LLC to use their information in a case study and may request a copy of the case study if so desired. They appreciate Ampersand Essentials Aromatherapy LLC’s dedication to using the highest quality, therapeutic grade essential oils.

I understand and agree to all of the above: *

Please sign this document by providing your first and last name.

I am the legal guardian of my child: *

Please provide your child's full name and age.

Date Signed *

YYYY

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