Client Intake Health Form
Hello! Thanks for choosing Ampersand Essentials Aromatherapy LLC for your aromatherapy and alternative medicine needs. Please fill out the following form to help us get to know you before our first appointment. We appreciate you so much!
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MAILING ADDRESS *
PHONE NUMBER
EMAIL
OCCUPATION
BIRTHDAY
MM
/
DD
/
YYYY
EMERGENCY CONTACT
Please include name, phone number and email.
CONDITIONS REQUIRING MEDICAL PERMISSION *
In circumstances where medical permission cannot be obtained, clients must give their informed consent in writing prior to treatment (select if/where appropriate):
Required
CONDITIONS THAT MAY RESTRICT TREATMENT *
(select if/where appropriate):
Required
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