Vaginal Steam Bath Intake Form

Name / Relationship / Phone:
What are your intentions/expectations for this visit and what are your major complaints or conditions you want to improve?
(an abnormal absence of menstruation.)
•If you are pregnant or there is a possibility of pregnancy •During or after ovulation if you are trying to conceive •During menstruation•With any open wounds, sores, blisters or stitches •If you have a vaginal infection or fever •Piercings will need to be removed
If you have an IUD................................. Steams help release matter from the uterus. To date, there are no incidents of IUD's being released with vaginal steam baths. They are on the caution list but no longer contraindicated. However, I will ask that if you have an IUD, you sign a release form that you are aware of the possibility of your IUD releasing
I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner so that the temperature may be adjusted to my level of comfort. I further understand that vaginal/yoni steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the vaginal/yoni steam bath is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because vaginal/yoni steam baths should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so.I am aware and I understand there is a possibility that my IUD can come out due to a Vaginal Steam Bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk.I understand that I am having this vaginal/yoni steam bath at my own risk and hereby release Journey to Calm llc, and/or Nonika Brown any liability.