Thebox:V'Jinga Party Intake Form

Party Yoni Steam Client Intake Form

Date

Name

Date of Birth*

Date

Address

Street Address Line 2

City / State / Zip

Phone

E mail

example@example.com

Emergency Contact

Relationship

Phone

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

This is my first time Steaming?

Do you have any allergies?

Please list Medical Diagnosis? (Ex: High Blood Pressure, Endometriosis, Ovarian Cyst)

If so, By whom?

Please Mark Any of the Following that Apply:*

Please indicate any explanations for the above if needed

IMPORTANT

The above "Yes" replies indicate that vaginal steaming is contraindicated. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not be performed at this time.

When Yoni steams should be avoided:

• If you are pregnant or there is a possibility of pregnancy

• During or after ovulation if you are trying to conceive

• During menstruation

• Fresh spotting or spontaneous bleeding

• With any open wounds, sores, blisters, or stitches

• If you have a vaginal infection or fever

• Piercings will need to be removed

• Birth control implant (Nexplanon, Implanon)

• Infection with burning

• Tubal Coagulation

CAUTION

If you have an IUD, Yoni steams help release matter from the uterus. 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.

Photography, filming, and podcasts disclaimer:

Please note that photographs and footage will be taken at any thebox:V'Jinga events. These will be used by thebox: V'Jinga for marketing and publicity in our publications, on our website and in social media, or in any third-party publication. Please contact the company if you have any concerns or if you wish to be exempted from this activity.

FINANCIAL POLICY

Thank you for choosing us for services. We are committed to providing you with the
best possible atmosphere and experience at the lowest possible cost. The following is our Financial Policy that we require you to read and sign.
Full payment for services is due at time of appointment. We accept cash, checks (with ID) or Visa/MasterCard, Cashapp. There will be a charge of $50 for returned checks and future checks will not be accepted.
This steam party is usually 15 minutes to ensure your body doesn’t have any negative reactions to the herbs or the steaming process. Follow up steams are $45.00 and last 30 minutes. We also have packages available to give you a better value for the service.
See your steam facilitator for pricing options for the packages.
In order to keep our fees to a minimum, a deposit is due now and the remaining balance is required at the time of service.

For unaccompanied minors, non-emergency treatment will be denied unless charges have been preauthorized to a Visa/MasterCard or payment by cash or check.

This information is stored in a password protected computer and would only be charged in the event of a No-Show or late cancellation with less than 4-hour notice.

Please give us 4-hour notice in advance if you cannot keep your appointment for any reason.
The deposit is nonrefundable for No-Show/late cancellation for all services. This policy will be enforced.

Please sign below*

Thebox:V'Jinga

Contraindications