Consent – Aromatherapy Form – Essential Healthcare Australia

CLIENT INFORMATION / DETAILS

Full Name Date of Birth Email Mobile Contact

Your Street Address Your Suburb State Post Code

Appointment type Date of Appointment Appointment Time

ABOUT Clinical Aromatherapy Practice

The practice of Clinical Aromatherapy is a branch of Phytotherapy that utilises concentrated plant extracts in the form of distilled and expressed essential oils to influence therapeutic outcomes.

Essential Oils are concentrated and intensely energetic in their effects which require safe application practices.

Clinical Aromatherapy is best supported in a clinical setting or by a professionally trained practitioner to safeguard therapeutic applications in the promotion of positive outcomes for health and wellbeing:

WHAT TO EXPECT during a consultation

Aromas can open the gateway of the mind and bring forth memories, emotions and/or feelings that can be intentionally directed.

As a result, change may be experienced at one level to effect transformation on another. Personal transitions can take the form of emotional, cognitive, behavioural and/or spiritual modification.

Change management is designed to ensure that reframing and/or reconstruct is implemented in a supported environment that safeguards concrete and successful transitions to result in adoption of change.

During the consultation, your aromatherapy practitioner will guide your through your medical history and, if your concerns are of a mental health nature, a thorough mental health history may then be taken.

In consultation, you will receive all relevant information regarding your consultation including treatment plans, social education, alternative courses of action, fees and costs and if applicable, dietary modification, benefits, risks and side effects of aromatic prescription and/or aromatherapy therapeutic application.

I acknowledge I have read and understand the expectations of Clinical Aromatherapy Practice.

General Medical Rules - Informed Consent

Please "tick" each box to indicate that you have read and acknowledge the following:

I give consent / agree that:

I acknowledge that this consultation is designed to gather information for the clinical purpose to formulate a customised aromatherapy treatment plan aimed to achieve the desired therapeutic outcome.
I acknowledge that Aromatherapy does not replace medical consultation; does not diagnose a medical condition; does not treat for special illness and/or prescribe or modify medications
My health information is recorded in a medical file and will not be released to others unless so directed by myself or if law requires
My health information may be shared and discussed between other healthcare providers for medical support
My intake form is completed prior to consultation and all information is honest, accurate, current and true
Details of any / all medical / mental health condition(s) and history are fully disclosed
I notify of any changes that may affect my health profile
My medical information and treatment plans are confidential, filed securely and electronically recorded
My information will not released to others unless so directed by myself or if law requires
My case file may be discussed with another healthcare provider for medical support
Services are provided to me under the instructions of my treating Clinical Aromatherapy Practitioner
that relevant medical referral may be included in a clinical aromatherapy consultation
I have been provided with information regarding consultation and treatment including a clear outline of outcome goals and objectives I acknowledge I have read and understand the General Medical Rules for Clinical Aromatherapy Practice consent

Clinical Aromatherapy Practice Rules - Informed Consent

Please "tick" each box to indicate that you have read and acknowledge the following:

ALL essential oil products are to be kept out of the reach of children
Consultation does NOT include ingestion or internal consumption of essential oil products
Essential Oils could be poisonous if swallowed
Essential Oils should be stored in a cool, dark place for maximum longevity
Essential Oils may irritate the skin if not stored correctly
Essential Oils may irritate the skin if applied incorrectly (above recommended dosage)
Essential Oils must not be used on the skin UNDILUTED
Essential Oils must be kept away from eyes and mucous membranes
Essential Oils must not be used with animals without professional advice
Essential Oils must not be used undiluted / diluted on the skin of babies / children < 1yo
Essential Oils must be used with extreme caution for children < 5yo
I acknowledge I have read and understand the Clinical Aromatherapy Practice rules

By signing this form, I give my consent to:

Aromatherapy Consultation

Customised Treatment Plan

Client Signature Guardian Signature (If applicable)