Thank you for your interest in a 7-Day Essential Oil Experience. This form will help me to determine which experience is best for you.

First Name *

Last Name *

Cell Phone *

Email *

Address *

City *

State *

Postal code *

Who invited you? *

Bridget Horton
Desiree Elliott
Someone Else
Social media
I don't know
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Which health concern would you like to focus on during your experience? *

Allergies
Digestion
Metabolism
Pain
Sleep
Stress/Anxiety
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What prompted your interest in this experience? *

Improving your lifestyle
Becoming more healthy
Being more proactive about your health
Essential Oils
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Do you agree to participate in our Kick-off and Wrap-up Zoom meetings? *

Yes
No (I'd rather do the self pace experience)
I have a conflict and I will discuss it with the person who invited me
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Do you agree to follow the protocol through the entire study? (If a negative reaction occurs, please discontinue use and contact the person who invited you) *

Yes
No (By selecting this answer, it disqualifies you from the experience)
Other (I will discuss this with the person who invited me)
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Do you agree to give honest feedback with the person who invited you? (We want to help you find solutions to assist you) *

Yes
No (By selecting this answer, it disqualifies you from the experience)
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Are there any health concerns we should be aware of (allergies, medications or health limitations) Explain *

Do you agree to setup and meet with the person who invited you to the experience for a personal follow up, so that they can help you find solutions? *

Yes
No (By selecting this answer, it disqualifies you from the study)
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Would you prefer to opt into communication via text or email? *

Text
Email
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By providing my phone number and email, I agree to receive text messages and/or emails from Healing at the Source. I am aware that I can opt out at anytime.