Fill out the Form for an Aromatherapy Blend

The following questions must be answered to provide a formulation

Describe the condition you are interested in attempting to heal with Aromatherapy below

How long has the condition persisted

Has it been reoccurring?      Yes     No

Is it now or has it been treated by a physician?     Yes     No

Are perscription or homeopathy medications being taken?      Yes     No

Is the formula user;
        Male or Female? Male Female -=Make Selection=-  
        If female, are you pregnant? Yes No -=Select=-           Nursing? Yes No -=Select=-
        Going through menopause? Yes No -=Select=-

        How old?            How tall?           Weight?

Body type?
        Obese   Large Boned   Heavily Muscled
        Average for weight and height  Frail or infirmed

Does the user of the oil have any allergies (especially to plants)?    Yes    No
    If so please list with comma separating each.

Are there scents that the user dislikes?

What plant scents does the user particularly like?

Name:
Contact Email:

Before formulating your blend, I may need to contact you by email for further details

You may chose to receive a formulation only; or at no additional charge you may receive a 15 ml bottle of the blend

I wish to receive only the formula                    I would like my blend sent to me at the address below
                                                                            Name:
                                                                            Mailing Address:
                                                                           

Please keep in mind that some of the ingredients are difficult to procure.
At this time I am trying to keep this on a donation rather than fee charged basis.
Please be reasonable within your means to donate. I have set a minimum of $7.00 U.S. for donations.
I have used the Amazon.com donation system for ease of use and your security.
I reserve the right to refuse service to anyone without advance notice.

Aromatherapy is not a medical form of treatment. It is a holistic form of healing.  The essential oils do have natural chemical consituents, 
which have been scientifically verified as having effect on some body conditions. 
as a replacement for a medical examination or treatment by a physician.  You should always keep your care provider advised of any 
complimentary/alternative medicine that you combine with traditional medical treatment. I am not a physician and therefor may not 
diagnose nor prescribe.