Raindrop Therapy Technique Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Are you currently under the care of a Physician? If so, please provide physician's name. * How did you hear about us? * Have you ever had a Raindrop Therapy Technique session before? * Do you have an area of concern? Please describe in detail. * Are you sensitive to essential oils? * Yes No If so, please list below which oils you are sensitive to. If the oil is not listed, please add it. Oregano Thyme Basil Cypress Wintergreen Peppermint Marjoram Valor White Angelica Please list oils that are not part of the list, if applicable. I understand that Raindrop Therapy Technique is an application of oils. I understand that essential oils will only be used topically and in proper diluted form. I have thoroughly read and acknowledge that I do not have any conditions contraindicated for the use of essential oils. I am not taking any medications nor do I have any medical conditions that may cause an interaction with essential oils. I acknowledge that I have the option to do a patch test today on my forearm prior to my treatment. I also understand that human responses to essential oils may vary considerably and are not predictable because of the unique chemistry, make up, and intent of each individual. I understand that the natural therapies offered by Purple Healing, LLC are not a substitute for adequate medical care and all healing may cause some minor discomfort, and some adverse side effects may occur through no fault of my own or Purple Healing, LLC. I understand that Purple Healing, LLC will not diagnose, suggest any treatment, prescription or cure for any disease, disorder, or condition that I may have or perform medical treatment of a licensed medical professional. I understand that Raindrop Therapy Technique does not take the place of medical care. It is recommended that I see a licensed medical professional for any physical or psychological problem I may have. I understand that Raindrop Therapy Technique can complement any medical or psychological care I may receive. I understand that the use of essential oils may help me improve the quality of my life. I acknowledge that long-term imbalances in the body sometimes require multiple sessions in order to facilitate for the body to heal itself. I affirm that I have stated all my known medical conditions honestly. I have thoroughly read and acknowledge that I do not have any conditions contraindicated for the use of essential oils. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. I understand my identity and information about me will be held in the strictest confidence, except when released by me in writing or as required by law. I acknowledge that I have read and understand this form. Typing my name and the date and checking " I agree" below acknowledges my understanding of the above. * I agree I disagree Cancellation Policy: Thank you for purchasing a session/ multiple sessions. When booking a service, if you should need to cancel or reschedule, please inform Purple Healing, LLC within a minimum of 48 hours by your scheduled appointment. This will allow Purple Healing, LLC to find a replacement client in time. However, if you cancel after the required minimum 48 hours or fail to show, you will be charged the full service fee which cannot be used for a future session. Please understand when cancelling late or not showing up, this does not leave Purple Healing, LLC enough time to inform clients that are on a waitlist of a potential available time slot. This is not to scold you but to be respectful of Purple Healing, LLC time and your time. Life can be hectic and emergencies may arise but its important that we all respect each other’s time. Thank you for your understanding. * I agree I disagree Signature * Date * MM DD YYYY Thank you!
