Men's Intake Form

Name *

First Name Last Name

Email *

example@example.com

Date *

Date

Phone Number

Area Code Phone Number

Do you have an infection characterized with a burning itch? * *

Do you currently have or had: herpes, HIV/AIDS, trichomoniasis, HPV, Gonorrhea, Chlamydia, Syphilis, PID or any other type of STI? Please specify in the comments section. *

Comments:

Are you prone to infections or viruses? *

Do you have any Food or Plant Allergies? *

Do you have any questions prior to your Lingham Steam Session?

If steaming causes a rash, bumps, headaches, itchiness, diarrhea or the onset of fresh spotting or inter-period bleeding (for women), this could be a sign that your steam protocol or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur, please let your practitioner know so they can adjust the steam session as necessary or make a referral.

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In 99% of all cases using a mild (10 minute) steam session and mild herbs will prevent any of the above signs from happening so it's very important that you give honest answers in this intake form so that the practitioner can set up a steam session that will fit your needs.

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General: I recommend that you consult with a qualified healthcare practitioner if you have any concerns using any herbal products. For educational purposes only. This information has not been evaluated by the Food and Drug Administration. This information is not intended to diagnose, treat, cure, or prevent any disease.

I understand that vaginal/penis steaming may have positive or negative side effects as a result of doing a steam session. I accept legal responsibility for my choice to do a reproductive organ steam session and waive the responsibility of the practitioner and the facility where the steam session takes place in the case that any of the named side effects (or others) may occur.

Signature *

Clear