Home | profile | About Aromatherapy | contact | Consultation

Home

Consultation Form

After the diagnosis from a physician, Aromatherapy Consultations may be done. The consultation includes discussion on particular health-wellness issue, essential oil or custom blends appropriate for self-care applications including a description of the medicinal properties of the essential oil with usage suggestions.

1 Month package - 50USD. Package includes online consultation, customised remedies as required.

Shipping charges extra as actuals.

(* represents compulsory fields )

Personal Contact Information

*Your Name :
Sex :	Male Female
*Street Address :
*Phone :(Include Country/Area Code)
*Country :
*Email :
Age :
Date of Birth:
Marital Status:
Children:
Occupation:
Name of Doctor:
Address of Doctor:
Telephone No. Doctor :

Case History

Do you know of any oil that you are allergic to?
If yes then mention the oil/oils
Have you had or are suffering from Cancer?
Are you/could you be pregnant?
Date of LMP :
Skin type:	Dry OilyNormal
Face:
Body :
Any acute health issues
Any chronic health issues
Any emotional stresses
Any physical stresses
Any skin sensitivities
Any spinal problems?	Posture ShouldersBack
	Neck Lumber

Do you suffer from/or have any of the following?

Heart problems	High Blood pressure	Low Blood pressure
Varicose veins	Multiple sclerosis	Arthritis
Rheumatism	Broken bones/ strains	Menstruation
Birth Pill	Hay fever	PMT
Anxiety	Kidney problem	Indigestion
Gall stone	Constipation	Diarrhea
Bronchitis	Colds/Flu	Asthma
Eye problems	Ear problems	Migraine
Headaches	Insomnia	Nervous stress
Nervous stress	Diabetes	Epilepsy
HIV	Psoriasis	Eczema
Sinusitis

Any other that you would like to mention?
Are you wearing contact lenses?
Any recent Operations?
Do have any other medical condition/illness?
Are you on any medication?

Do you?

Take supplements
Smoke (How many per day)
Drink alcohol (Units per week)
Do you find time for relaxation and hobbies?
Is there any other condition which you think would affect you having therapy?
*Reason for treatment

Fragrance preferences:

Floral		Citrus	Herbaceous	Exotic
Woody		Earthy	Spicy

*Enter the code shown on image:

Disclaimer
I have answered truthfully. I understand the therapist has gone through this consultation with me, to identify if there are any contra-indications that would affect me having a treatment. I also understand that this is to safeguard me as well as the therapists. I therefore do not hold the therapist Rupal Shabnam Tyagi liable.

Send me a copy of this enquiry

Some clients may have the following symptoms for upto 48 hours after a therapy. Headaches, emotionally upset, lethargic, energized, flu like, achy. This is the result of your mind and body absorbing the essential oils.

Kindly perform a patch test before using any new blend on your skin.

Contact us

Wikka
Mrs. Rupal Shabnam Tyagi
R.A.Arom (London)
C- 6/6323, Vasant Kunj
New Delhi, Delhi - 110 070 (India)
Mobile No. : 9818289464

Click to Call Free Send SMS / Text Message

E-mail: wikkaroma@yahoo.com

S-341, Panchsheel Park,
New Delhi, Delhi - 110017 (India)
Note : Mon and Wed. (12pm to 6pm.)

Aromatherapy Treatment for
Skin Care	Hair Care	Mind Care	Body Care	Babies & Children
Our Products
Hand Sanitizer