Were the Essential Oils used on a human? If so, state gender and age if known

Were the Essential Oils used on an animal? If so, state breed and age if known (see below)

What Essential Oils were used: (list all individual oils and blends inc. botanical name if known)

How were they used, (oral ingestion, topically, bath, diffusion etc.)

Were the essential oils diluted or used undiluted (neat application) (and then diluted):

What was the percentage of essential oil used: (how many drops, ounces etc. if known):

How many applications:

Essential Oil Brand used (if know):

Was the oil over 6 months old:

What was the experience during (symptoms, general feelings of discomfort, adverse reactions):

What was the experience immediately afterwards:

What was the experience sometime later (list how much time/days passed):

Describe if any; medical intervention (blood tests, other tests, etc) (include name of hospital, clinic, doctor, date of exam/tests):

What type of essential oil session did you receive (Massage, Nursing, Spa etc.):

Where did the essential oil session take place: (Spa, Massage Center, Hospital, Home etc.):

City and State Contact information phone number and email/website of the facility-practitioner:

Name of person who administered the essential oil session: (if available):

Dates of essential oil application/s:

If you are submitting data about your Pet´s essential oil negative reaction please include: (Pet´s name, Breed, Male/Female, Age, Health condition prior.)

Please use the above intake form to list how the essential oils or products were applied to the animal and what were the essential oils being used for and what was the reaction etc. You can use the Personal Testimonial Space to share more details.

Personal Testimonial Page: (Please use this space for additional details that you would like to share).

By submitting this data either via website, electronically, hand-written or in a typed document/disc to NAHA you hereby give NAHA permission to share this information with NAHA Board Members, NAHA Safety Committee, NAHA Members and for publication on the NAHA website, Aromatherapy Journals, Newsletters and as an educational awareness tool to help others. Any additional submissions or documentation including photos please include your full name and contact information.

Please type your name and initials. They will act as your signature/waiver