V-STEAM CONSULTATION FORM

V-Steam Consultation Form

Kindly Complete the V-Steam Consultation Form

Full Name*

Email Address*

Phone Number*

Date*

Address*

What are your intentions/expectations for this visit and what are your major complaints or conditions you want to improve?*

Are you pregnant or trying to conceive? How many pregnancies have you had? Terminations / When? Miscarriages / When?*

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, vaginal/yoni steam baths may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

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*

Email Address: Laritz1234@gmail.com

Phone Number: (770) 918-1380

Toll Free: (833) 953-1380
Mon-Sat: 10:00am-7:00pm, Sunday: Closed

Address: 905 Flat Shoals Rd SE, Conyers, Ga 30094