Postpartum Steaming Intake Form

Postpartum Vaginal Steaming Intake Form

Adapted form by the Peristeam Hydrotherapy Institute

Medical Disclaimer: As with all health and wellness information, it is always recommended to consult your healthcare provider before beginning any new treatment or program. The information and recommendations provided are not intended to serve as or replace medical advice and should not replace a professional diagnosis or treatment of a health problem or disease. These services do not substitute for professional medical care. The practitioner assumes no responsibility or liability for any consequence resulting directly or indirectly from any action or inaction you take based on the information provided or offered. The practitioner cannot guarantee the outcome of following the recommendations provided and the statements about the potential outcome are expressions of opinion only. By continuing with this intake form, consultation, and following recommended protocols and use of herbal blends you acknowledge that the practitioner makes no guarantee of any particular results or outcome and that outcomes are based on subjective factors that are not within our control. Therefore, acting on any information or following any recommendations or protocols are done at your own risk. If you need medical advice, you should hire a licensed medical provider. This form and waiver is required before continuing with any consultation.
Client Name*

First NameLast Name
Client Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address (non-local shipping)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth (minors only)

MonthDayYear
Date
Current Date

MonthDayYear
Date
Your Practitioner's Contact Details
Practitioner Name: Heidi Pyper

Practitioner Email: heidipyperdoula@gmail.com

Practitioner Phone: 385-505-4082

What to Expect

The Main Purpose of Pelvic Steaming is to:
- Increase circulation & fully cleanse the uterus
- Disinfect
- Deodorize the pelvic area
- Support the health and/or positioning of the uterus and neighboring organs
- Tighten the pelvic floor and vaginal canal
- Relax the mind and body
- Menstrual health
What to Expect After Your Steam:

There are many reported benefits of vaginal steaming including:
- Relaxation
- Deep Sleep
- Increased Vaginal Nectar (clear pleasant-smelling fertile mucus)
- Heightened Libido and Sexual Sensation
- Heightened Fertility
- Circulation Improvement
- Decreased PMS Symptoms
- Water Retention Dispersement
- Emotional Balance
- Skin Beautification
- Tightened and Lifted Vaginal Canal
- Scar Softening
- Helps Prevention and Treatment of Ingrown Hairs
Steaming also has a great cleansing effect. That is the main goal of steaming, to clear out the stagnation and old residue in the uterus and vagina. All of these signs are normal and expected to resolve once the cleanse is complete. Please note changes and inform your practitioner.
- Increased menstrual cycle clots, which should dissipate more with each period if doing regular steam sessions
- Increased menstrual cramps due to the uterus trying to clear old residue.
- Increased cramping when not on period. This should get better doing regular steam sessions.
- Increased Irregular Vaginal Discharge or Odor (white, green, thick, clumpy). This is old mucus from prevous or current infection that is getting cleared now.
- Brown discharge after steaming. This is old blood and residue that we want to clear out. You may want to wear a panty liner if there is a lot.
- Itchiness (Can be caused by discharge with any yeast, bacteria, viruses). Use a peri bottle with water and ACV during the day to help.
- Emotional Release.
Additional signs of cleanse that are normal:
- Earlier or later menstrual cycles - a change of a few days earlier or later is normal. The body may sync up with the new moon or full moon.
- Urination urge while steaming
- Sexual arousal - the increased circulation to the vaginal area can heighten libido
What to Expect

The Main Purpose of Pelvic Steaming is to:
- Increase circulation & fully cleanse the uterus
- Disinfect
- Deodorize the pelvic area
- Support the health and/or positioning of the uterus and neighboring organs
- Tighten the pelvic floor and vaginal canal
- Relax the mind and body
- Menstrual health
What to Expect After Your Steam:

There are many reported benefits of vaginal steaming including:
- Relaxation
- Deep Sleep
- Increased Vaginal Nectar (clear pleasant-smelling fertile mucus)
- Heightened Libido and Sexual Sensation
- Heightened Fertility
- Circulation Improvement
- Decreased PMS Symptoms
- Water Retention Dispersement
- Emotional Balance
- Skin Beautification
- Tightened and Lifted Vaginal Canal
- Scar Softening
- Helps Prevention and Treatment of Ingrown Hairs
Steaming also has a great cleansing effect. That is the main goal of steaming, to clear out the stagnation and old residue in the uterus and vagina. All of these signs are normal and expected to resolve once the cleanse is complete. Please note changes and inform your practitioner.
- Increased menstrual clots, which should dissipate more with each cycle if doing regular steam sessions
- Increased menstrual cramps due to the uterus trying to clear old residue.
- Increased cramping when not on menstrual cycle. This should get better doing regular steam sessions.
- Increased Irregular Vaginal Discharge or Odor (white, green, thick, clumpy). This is old mucus from prevous or current infection that is getting cleared now.
- Brown discharge after steaming. This is old blood and residue that we want to clear out. You may want to wear a panty liner if there is a lot.
- Itchiness (Can be caused by discharge with any yeast, bacteria, viruses). Use a peri bottle with water and ACV during the day to help.
- Emotional Release.
Additional signs of cleanse that are normal:
- Earlier or later menstrual cycles - a change of a few days earlier or later is normal. The body may sync up with the new moon or full moon.
- Urination urge while steaming
- Sexual arousal - the increased circulation to the vaginal area can heighten libido
Caution Signs

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

In most cases, using a mild no-heater steam session and custom herbs will prevent any of the above signs from happening. It is important to fill out this form honestly and completely so that steaming sessions can be adjusted to fit your needs.
Do You Have Any Questions or Hesitations Prior to Your Vaginal Steam Session?

Billing and Payment

$90 for virtual intake consultations which include:
- Custom herbal blend with 30 steam sessions
- Steaming education including benefits, instruction, and best practices
- Intake completion and review
- Recommended protocol (when and for how long to steam with a regular routine)
- Discount for birth and postpartum clients - $55 total
$15 for steam stool rental (6 weeks) or $65 steam stool purchase. If steam stool is not returned within 6 week window, client is responsible for full purchase costs.
Selection and Add Ons

$90 Vaginal Steaming Intake Consultation (zoom or phone, includes custom blend with 30 steam sessions)$55 Discounted Postpartum Vaginal Steaming as add on for clients (consultation, custom blend with 30 steam sessions)$15 steam stool rental (local only, 6 weeks). Drop off return required if rental extends beyond postpartum service agreement visits.$65 steam stool purchase (if available, local pick-up only or drop off for birth and postpartum clients)
Notes on Selection (if applicable)
An invoice will be sent to the email provided in this intake form. Payments are due before or after the consultation (same day) and can be made via:

venmo: @heidipyper

Paypal (including processing fee): heidipyperdoula@gmail.com

Cash: (in-person only)
INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

Below is a legal waiver between the practitioner and the client stating that the client will not sue the practitioner in the event that something undesireable occurs. Filling out this waiver is required to receive products or services from the practitioner.
Client Name*

First NameLast Name
THIS AGREEMENT is made between Heidi Pyper, Maiden to Mother (as typed in the practitioner section below) (“Company”) and Client (as typed in the field above) ("I") (collectively the “Parties”).

I have purchased or am receiving complimentary steaming services, products or a consultation from Companies (the "Products and/or Services").

I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in, or cause me to have an adverse reaction to, the Services, including but not limited to preterm pregnancy. I affirm that I have reviewed the “Best Practices” and other information provided to me by Company or its agents. I further affirm, that all information provided to Company by me is accurate and complete and I understand that failing to provide information may result in a greater risk of injury. I acknowledge that my purchase and participation in or use of the Products and/or Services is voluntary and I do so entirely at my own risk. I acknowledge that I have approval from my doctor or medical professional to use or receive the Products and/or Services or I yield that requirement and take responsibility for my own medical decision-making.

I understand that results may vary from person to person. I understand that I may react adversely to the Products and/or Services and they may result in injury to me. Side effects include, but are not limited to, rash, bumps, headaches, itchiness, diarrhea, increased vaginal discharge, cramping or the onset of fresh spotting or inter-period bleeding. If I elect to continue Products and/or Services after such results, I will alert Company to issues so that the Products and/or Services may be adjusted, or a referral can be made. I expressly agree that all risk of injury that I undertake as a part of the Products and/or Services is undertaken at my sole risk.

I further expressly agree that I will not use any equipment related to the Products and/or Services improperly. If equipment is located on the Company premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release Company, its agents and employees from any claim, demands, injuries, damages, actions, or causes of action, that could occur from my inappropriate use of such equipment.

I also understand and agree that all information provided before, during, or after the Products and/or Services is for informational purposes only and is not a replacement for medical advice from a physician or pediatrician. The Products and/or Services and information provided therein does not replace the relationship between physician/therapist and a client in a one-on-one treatment session with an individualized treatment plan based on their professional evaluation. The Products and/or Services and any information therein are provided "as is" without any representations or warranties, express or implied.

I will not rely on the Products and/or Services as an alternative to advice from my medical professional or healthcare provider and I will never delay seeking medical advice, disregard medical advice, or discontinue medical treatment as a result of any information provided before, during, or after the Products and/or Services. I understand and agree that all medical related information is for informational purposes only.

Company, its agents and employees, shall not be liable to me for any claims, demands, injuries, damages, actions or causes of action to my person or property arising out of or connected with the Products and/or Services and the premises where the Products and/or Services are located. I expressly release Company, its agents and employees from all such claims, demands, injuries, damages, actions, or causes of action, and from all acts of active or passive negligence on the part of Company, to the extent such a release of negligence is permissible by law.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during the Products and/or Services. In the event of sickness, accident, or injury, I authorize Company and its representatives to obtain, on my behalf, emergency medical treatment at my expense.

This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. This Agreement shall be construed and enforced according to the laws of the State of Utah and any dispute under this Agreement must be brought in this venue and no other.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I UNDERSTAND AND AGREE THAT I AM GIVING UP LEGAL RIGHTS BY SIGNING THIS AGREEMENT AND THAT I AM DOING SO VOLUNTARILY, FREELY, UNDER NO THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE, OR GUARANTEE BEING COMMUNICATED TO ME. THE SIGNATURE BELOW IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW.

My printed name and date below represent my signature.
Client Name (Signature)*

First NameLast Name
Date of Signature*

MonthDayYear
Date
End of Client Section

Thank you for filling out this form. This is the end of the client intake form. Please mark submit below to send this information to your practitioner.
Practitioner Section

Practitioner Name: Heidi Pyper

Practitioner Company: Maiden to Mother
Should be Empty:

	Yes	Sometimes	At First But Not Now	No
Heavy (more than one pad per hour)
Increasing in Flow

	Yes	Sometimes	At First But Not Now	No
Light Lochia Flow
Medium Lochia Flow
Lochia Goes Away and Then Comes Back
Uterine Contractions/After pains
Red Color
Brown Color
Pink or Orange Color
Clots
Stringiness

	Yes	Sometimes	No
Brown Discharge
Fresh Spotting (red or pale pink)
Brown and pink spotting?
Friendliness

	Yes	Sometimes	At First But Not Now	No
Uterine Prolapse
Uterus Hasn't Returned Down to Size Yet
Uterus is in the Wrong Position, Tilted or Retroverted

	Yes	Sometimes	At First But Not Now	No
Hemorrhoids
Difficult Urination
Bladder Incontinence
Constipation
Bladder Prolapse
Colon Prolapse
Fistula
Difficult or painful urination
Swollen urethra

Postpartum Vaginal Steaming Intake Form

Your Practitioner's Contact Details

Client Information

Reproduction Phase

Benefits of Postpartum Vaginal Steaming

Lochia

Steam Sensitivities

Medications and Health Conditions

What to Expect

The Main Purpose of Pelvic Steaming is to:

What to Expect After Your Steam:

What to Expect

The Main Purpose of Pelvic Steaming is to:

What to Expect After Your Steam:

Caution Signs

Billing and Payment

INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

End of Client Section

Practitioner Section

	Yes	Sometimes	At First But Not Now	No
Tear + stitches
Tear + no stitches
Episiotomy - stitches
Swollen labia
Irritated Stitches
Stinging Urination Due to Stitches
Irritated tear
Damaged tissues from labor interventions (i.e. forceps)

	Yes	Sometimes	At First But Not Now	No
Thirst
Headaches
Low Milk Production (with soft breasts)
Hair Falling Out
Teeth Hurting
Dry Skin
Chapped Lips

	Yes	Sometimes	In the Past, But Not Now	No
Infection (i.e. HPV, Herpes, Yeast Infection, Bacterial Infection, UTI, etc.)
Abnormal Vaginal Discharge (i.e. green, yellow, white, thick, malodorous)
Fever
Night sweats
Hot Flashes
Infected tear and/or stitches

	Yes	Sometimes	In the Past But Not Now	No
History of Short Menstrual Cycles (27 days or shorter)?
Did Labor Start Naturally Prior to 38 Weeks?
Did You Have Any Fresh Spotting During Pregnancy?
Has the Menstrual Cycle Returned Within 9 Months of Giving Birth?
Are you 30+ Days Postpartum and still clearing lochia?
If yes, does the lochia include fresh blood?
Did you Experience Postpartum Hemorrhage?
Do You Have A History of Spontaneous Bleeding?