Holistic Wellness Form

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

First Name

Have you used essential oils before?

Yes

Last Name

Date of Birth

Are You currently Pregnant

Yes

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

Yes

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

List any known allergies, including allergies to specific herbs, 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.

Wellness Disclaimer
MC Integrative Wellness provides essential oil and holistic wellness products for educational, self-care, and general wellness purposes. These products and recommendations are not intended to diagnose, treat, cure, or prevent any disease or medical condition and are not a substitute for medical or mental health care. Individual responses to essential oils and botanical ingredients may vary. Please disclose known allergies, sensitivities, pregnancy, medications, and relevant health concerns before use. Consult a qualified healthcare professional when appropriate.

I confirm that the information I have provided is accurate and complete, and I acknowledge that I have read and understand the Wellness Disclaimer.

Need More Personalized Guidance?

If you're unsure which wellness options may best support your needs, schedule an Integrative Wellness Consultation for personalized educational guidance on oils, herbs, flower essences, and holistic wellness practices.

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Integrating Mind, Body, & Purpose

Holistic Wellness Form