Yoni Steam Confidential Client Intake Form Step 1 of 3 33% Date MM slash DD slash YYYY Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneEmail (We will only use your email address to send out Spa information/updates, and appointment confirmation. No personal health information will be sent via email.)Birthday MM slash DD slash YYYY How Did You Hear About Us?May we contact you via mail/email about future promotions/news? Yes No Emergency Contact NamePhoneAll information received on this form will be treated as strictly confidential. Please fill it out completely and accurately. This information is essential to help your Yoni Steam Practitioner safely and effectively develop your personalized wellness program; specifically, the herbal blends that address your needs, goals and interests.GENERAL & MEDICAL INFORMATION IN THE LAST 6 MONTHS (Check all that apply) Bacterial Vaginosis Breastfeeding Endometriosis Fibroids Infertility IUD Menopause Miscarriage Pain PID PMS Polycystic Ovaries Prolapsed Uterus STI Vaginal Piercing Vaginal Surgery Pregnant (Do Not Steam If You Are Pregnant, or Think You May Be Pregnant Please indicate any mental discomfort that you are experiencing (Check all that apply) Anxiety Anger Compulsive Confused Excess Stress Grief/Sadness Headache Lack of Energy Hyperactive Memory Trouble Unfocused Consistently Frustrated/Annoyed Depressed Woman Should Not Yoni Steam If They Experience: extremely heavy menstrual cycles;on your period; have a vaginal infection;open wounds, sores, blisters;if you are pregnant or think you are. If you have genital piercings, take them out before steaming, the heat can cause the piercing to burn. If you have a IUD, your muscles get warm & relax and your IUD can fall out.I understand my Yoni Steam Practitioner does not diagnose any medical, physical or mental disorder or prescribe medication. This service is not intended to diagnose, treat, cure or prevent any disease. Those seeking treatment for a specific disease should consult a qualified medical, integrative or holistic physician prior to using our service. The statements and services offered have not been evaluated by the U.S. Food and Drug Administration. I understand that services offered are not a substitute for medical care and any information provided by the therapist(s) is for educational purposes only and not diagnostically prescriptive in nature. I agree that this intake form and waiver is in effect for all my Yoni(vaginal) steaming sessions and will not expire. I understand that I am free to withdraw my consent and stop Yoni steaming treatment at any time. The treatments and precautions above have been explained to me in detail and I fully understand.Consent to Above With Your Full NameDate MM slash DD slash YYYY For Spa Use OnlyTherapist/Practitioner SignatureDate MM slash DD slash YYYY Practitioner Notes Acknowledgement and Release from LiabilityThank you for choosing VP Steam Spa for your holistic womb wellness. In order to facilitate your request, it is important that you read and understand the following conditions: VP Steam Spa does not diagnose, treat, cure/claim to cure, or prevent any disease. We are not physicians and therefore do not diagnose disease or prescribe drugs. As VP Steam Spa Practitioners, our services are solely for the purpose of helping the client to attain and maintain optimum health. At all times your healing is your responsibility. Services provided through VP Steam Spa are not to be substituted for a physician’s advice. VP Steam Spa services are complimentary healing alternatives and are completely elective. You are hereby request and consent to receiving the Yoni & Lingam Steam, Oxygen Therapy, Massage Therapy and/or any other related services. You are required to advise your Yoni Steam Practitioner of any conditions, including pregnancy that may prevent you from receiving our services. You are required to inform your practitioner if at any time during your care you experience any pain or discomfort. You have been advised of the possible benefits of receiving Yoni Steams including but not limited to pain management, stress relief, cleansing, strengthening and toning of the uterus and the reduction of certain conditions. You are hereby advised that all records rendered by VP Steam Spa are kept confidential and will not be released without your written consent unless otherwise required by law. I hereby acknowledge that I have read the Acknowledgment and Release from Liability. I am satisfied and fully understand the nature of the services being provided and freely agree to receive them. I release VP Steam Spa and its Practitioners from any medical claims or malpractice, non-disclosure or lack of informed consent. I freely assume all risks of the services provided presently or hereafter. By typing your name below, you agree to the above disclaimer and release for VP Steam Spa to provide you their complimentary services.Consent SignatureDate MM slash DD slash YYYY For Spa Use OnlyPractitioner Signature VP Steam Spa PolicyNO REFUND – SPA CREDIT ONLY. CREDIT WILL BE APPLIED TO YOUR NEXT SERVICE OR PRODUCT PURCHASE. PLEASE CANCEL/RESCHEDULE YOUR APPOINTMENT WITHIN 24 HOURS. NO CALL. NO SHOWS FORFEIT YOUR DEPOSIT. NO EXCEPTIONS. First Time Visitors: Please arrive on time, or a few minutes before your appointment to allow time to complete your consultation form if unable to complete it online. Late Arrivals: As a courtesy to all of our guests, and in order to remain on time with our appointments, late arrivals will not receive an extension of service time and will be responsible for full-service fees. After 15 minutes, your appointment must be cancelled, and your deposit will be forfeited. Cell Phones: Please mute devices and cell phones. Age Requirement We do not service children under the age of 14. Entourage Policy: Due to limited space, please do not bring an extra guest with you unless they are receiving a service within the same time frame. Please note: children are not allowed to wait during your time of service. Cancellation Policy: We require a credit card deposit or a gift certificate number to secure an appointment time. VP Steam Spa takes pride in our ability to provide personal service to all of our clients. We require a 24-hour cancellation/change notice in the event that you need to cancel or reschedule your appointment. Same day no-shows/no calls will forfeit your deposit initially paid. Cancellations and no-shows affect us and other clients greatly and cannot be accepted without a penalty charge. By giving us your credit card information, you are authorizing deposits to be forfeited. Party bookings will forfeit ALL DEPOSITS if a cancellation is made less than 48 hours prior to the scheduled party. Sickness: If you have any cold, flu, or COVID-19 symptoms, your appointment will be canceled immediately, and a spa credit will be issued.Client SignatureDate MM slash DD slash YYYY For Spa Use OnlyPractitioner SignatureEmailThis field is for validation purposes and should be left unchanged.
