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Custom Blending Information
For current and future purchases of our custom blended products, we require the following information to be completed
Skin Type:
(if known ie Normal, Dry, Oily, Sensitive, Combination)
Do you suffer any skin conditions:

Examples include:
Psoriasis, eczema, dermatitis
Dryness or tightness
Pimples or blackheads on body
Scaling or cracking
Pimples or blackheads on face
Itchiness of scalp
Dry, flaky skin around nose, mouth or eyelids
Sensitivities or allergies
Rosacea or broken capillaries
Current Products:

Please list all of the cosmetic and pharmaceutical products you are currently using on your skin
Current Medication:

Are you currently on medication (including antibiotics)?

Please list these and the conditions to which each relates.
Do you suffer any health conditions:

High blood pressure
Low blood pressure
Recurring colds or viral infections
Menstrual problems
Varicose veins
Menopausal symptoms
Skin Infections ie cold sore, tinea, warts
Injury/Pain - please detail

Are you pregnant or breastfeeding?

No of weeks pregnant:

Are you tring to conceive?

Are you allergic to any animals, grasses, plants or food?

(Please detail)

 Essential Oil Aromas

(please enter any aroma preference)

(please enter any aroma preference)
Is there anything else we need to consider?

(Please detail)

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