Animal Aromatherapy Consultation -

Your Name *

First

Last

Email *

Phone *

Animal Name *

Animal Species (Dog, cat, horse, etc.) and Breed (if applicable) *

Animal Age *

Animal Gender (Female spayed, male intact, etc) *

Animal Weight *

History | Your concerns *

Veterinary Diagnosis and Treatment (Include medications. If none state so.)) *

Medical History Terms & Conditions *

Check this box to show you agree

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

I understand that the therapies we will be discussing are considered alternative forms of therapy and investigative by mainstream medicine:

Herbal Therapy: Including food therapy and supplementation

Essential Oil Therapy: Including Topical, Internal and Aromatic uses of Certified Pure Therapeutic Grade
Essential Oils

Miscellaneous therapies that may be discussed such as chiropractic and musculoskeletal manipulation and acupuncture

I understand that in no way is Deborah Robinson attempting to diagnose, treat, mitigate, or cure a disease by offering suggestions offered.

The nature and purpose of these possible alternative methods of treatment, risks involved, and
possibility of complications have been fully explained to me. I acknowledge that no guarantee or assurance
has been made to me as to the results that may be obtained.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Owner's Signature *

Date *

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