Yoni/Lingam Steam Intake + Consent Form

Yoni/Lingam Steam Intake + Consent Form
Appointment Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
Emergency Contact*
List full name and number of emergency contact.

Reproductive Health History

(For Female Clients)
When was the first day of your last period?*
Type N/A if unknown or you are a male client.
How often do your periods come?*
Type N/A if unknown or you are a male client.
How long do they last?*
Type N/A if unknown or you are a male client.
Are you under the care of an obstetrician-gynecologist (OB/GYN) for any current reproductive system issue or concern (i.e. birth control, abnormal pap smear, infertility, STI, etc.)?*

NoYesN/A (Male Client)
If yes, please explain:*
Type N/A if NO or you are a male client.
Do you have any concerns about your menstrual cycle?*
Do you have the Nuva Ring birth control currently inserted?*

NoYes (Please remove prior to steam session)N/A (Male Client)
Do you have an intrauterine device (IUD)?*

NoYesN/A (Male Client)
Some of the herbs in the steam could cause stronger contractions of the uterus and there is a possibility that your IUD can be released due to this treatment. Please initial that you understand this and that you are proceeding with the yoni steam at your own risk.*

Clear
Sign N/A if you answered NO or you are a male client.

I fully understand that yoni/lingam steaming does have possible negative side effects, such as risk of burns, allergic reactions, aggravation of existing conditions and disruption of vaginal pH balance. I understand that if I experience any pain or discomfort during any session, I will immediately inform the esthetician so that the temperature may be adjusted to my level of comfort. I am aware that the esthetician facilitating the yoni/lingam steam is not qualified to diagnose, prescribe and/or treat any physical or mental illness and that it should not be performed under certain medical conditions. I further understand that yoni/lingam steams should not be used as a substitute for medical examination, diagnosis or treatment and that I should see a medical provider or other qualified medical specialist for any physical or mental ailment of which I am aware. I have disclosed all of my known medical conditions and answered all questions accurately, completely and honestly and agree that it supersedes any previous verbal or written disclosures. I understand the procedure and accept the risks. I agree to keep the esthetician updated as to any changes in my medical history and understand that there shall be no liability on the esthetician's part should I forget to do so. I do not hold the esthetician, Brittany Miona Ward, and the institution, Miona Naturals LLC, responsible for any of my conditions that were present, but not disclosed at the time of this service, which may be affected by the treatment performed today. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I understand the post-treatment home care instructions will be available by email after my treatment is completed. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home/post-treatment care, I will consult the esthetician immediately. I hold the esthetician, Brittany Miona Ward, and the institution, Miona Naturals LLC, harmless from any liability that may result from this treatment. I understand rude or offensive behavior and language is NOT tolerated at any time and that the esthetician, Brittany Miona Ward, and the institution, Miona Naturals LLC, reserves the right to refuse service at any time.*

Yes
I consent to Miona Naturals: Esthetics + Spa to take photos and/or videos of me immediately prior to, during and/or after my procedure. I authorize Miona Naturals: Esthetics + Spa to copyright, edit, use and publish these photos and/or videos. I consent to Miona Naturals: Esthetics + Spa using such photos and/or videos for the purpose of documentation, education, social media, advertising and web content. I may indicate if I prefer not to have my full face shown. I understand that I will not receive any monetary compensation for usage of my photos and/or videos.*

Yes
Client Signature*

Clear
Esthetician Name
Date

MonthDayYear
Date
Should be Empty:

	Yes	No	N/A (Male Client)
Are you currently on your period?
Do you currently have fresh spotting?
Are you pregnant?
If trying to conceive, are you past ovulation?
Active STD, herpes outbreak?
Open sores, wounds or blisters in genital or rectal area?
Any type of genital/vaginal infection or active fever?
Are you fewer than 6 weeks postpartum?

Yoni/Lingam Steam Intake + Consent Form

Contraindications

Reproductive Health History

Reproductive Health History