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Holisticwellnes Form

Please fill out the following form in order to help with the oil best for you

First Name

Email

Have you used essential oils before? *

No

Yes

Last Name

Date of Birth

Are You currently Pregnant *

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If yes, please list any specific oils you have used and the purpose

List any known allergies, including allergies to specific essential oils or carrier oils.

Please describe any specific concerns you have regarding the use of essential oils. This could include relaxation, stress relief, pain management, skin care, or other objective.

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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