Animal Aromatherapy Consult Details Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *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 (Include all information that could be helpful which could include diet, environment, etc.) *Veterinary Diagnosis and Treatment (Include medications. If none state so.)) Also, include any other alternative treatments you've used including essential oils, herbs, etc. *(optional) You can attach any records here including a pdf with pictures if relevant. Click or drag files to this area to upload. You can upload up to 10 files. Medical History Terms & Conditions *Check this box to show you agreeBy 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 Bowen Robinson, Old Ways Made New, is 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 (Use your cursor to sign your name) * Clear Signature Date *You will be given an opportunity to schedule a time for your consult upon submission of this form if you haven’t done so already.Submit
