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Telfairi Natural Therapies
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Aromatherapy Blend Form
Please fill out this form so that I will be able to create a custom blend that is perfectly suited to you. This form will make sure that your blend will not agitate you or trigger any allergens.
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Your Details
Please fill in details of who the products are for. Shipping information is separate.
Name
*
First
Last
Email
*
Phone
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Medical History
Please give as much detail as possible. Include any condition or medication, including those you do not believe are relevant to your selected treatment as it may effect the choice of oils.
Please confirm any changes to your medical conditions or illnesses
Please confirm any changes to the medication you are taking
This includes off the shelf as well as any prescribed medication.
Do you have any allergies or sensitivities you are aware of that may affect the oil choice in your blend?
*
Please be as specific as possible, e.g. if you have hay fever, specify which plant pollen aggravates you.
Aroma Preference
Please rate your preference for the following aromas and scents:
Citrus (e.g. Lemon, Bergamot, Neroli, Petitgrain)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Earthy (e.g. Vertivert, Patchouli, Myrrh, Valerian)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Floral (e.g. Rose, Ylang-ylang, Clary Sage, Jasmine)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Fresh (e.g. Peppermint, Eucalyptus, Lemongrass, Black Pepper)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Fruity (e.g. Juniper, Lemon, Frankincense, Bergamot)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Herbaceous (e.g. Cypress, Thyme, Lavender, Basil)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Medicinal (e.g. Eucalypyus, Rosemary, Tea Tree, Lavender)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Spicy (e.g. Bergamot, Cypress, Black Pepper, Ginger)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Sweet (e.g. Basil, Ylang-ylang, Sandalwood, Chamomile)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Warm (e.g. Clove, Bergamot, Jasmine, Marjoram)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Woody (e.g. Tea Tree, Nutmeg, Sandalwood, Patchouli)
*
Strong Dislike
Dislike
Neutral
Like
Strong Like
Are there any specific scents that are your favourites?
*
Are there any specific scents that you cannot have or would not want used?
*
For example if you are aware of any scents you are allergic to or particularly hate, for example if you generally like fruity but hate the scent of oranges.
Additional Comments
Anything else you feel is relevant for completion of product.
Please check that all required questions have been answered.
Submit
✕
