The Somatic Womb Touch ™

Name*

First NameLast Name

Birth Date*

MonthDayYear

E-mail*

example@example.com

Mobile Number*

Instagram Handle

Reason for your visit/booking?*

Please check all that have or currently apply*

Do you have any allergies or sensitivities?*

How often are your bowel movements?*

Do you experience bloating/gas/burping? If so, when do you most commonly experience this (after eating, close to menstruation, under stress...)*

Do you experience numbness/pain in your lower abdominal area or low back? Please specify*

Do you use contraception? Please specify type - i.e pills, IUD etc*

Have you undergone any uterine related surgery? (This includes ovaries, cervix, Fallopian tubes) If so when?*

Do you currently suffer from any dis-ease or discomfort in your womb/sacral space? Please describe below*

Do you exercise?*

Are you pregnant? Think you are pregnant? Or trying to conceive? *

If applicable, please describe your overall experience with pregnancy/trying to conceive*

If applicable, please describe your experience with labor & post-partum*

What if your opinion of yourself? How do you see yourself? (Just a reminder that I will never ever judge or share this information. )*

What is your interest in sex?*

HighModerateLowNone

Do you have or ever had difficulty experiencing orgasms*

YesNoSometimes

I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have.

I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.

Risks and Benefits:

I understand that while Womb Touch is intended to promote well-being, it may involve risks, including but not limited to, temporary discomfort, emotional release, and physical sensations. I acknowledge that the Provider cannot guarantee specific outcomes or results from the Therapy.

Release of Liability:

In consideration of being allowed to participate in Womb Touch, I hereby release, waive, discharge, and hold harmless the Provider, its employees, agents, and representatives from any and all claims, demands, actions, or causes of action arising out of or in connection with my participation in Womb Touch, including but not limited to, any injuries, damages, or losses.

Confidentiality:

I understand that any information shared during the sessions is confidential and will not be disclosed to third parties without my consent, except as required by law.

Consent to Treatment:

I voluntarily consent to receive this service from the Provider. I understand that I may withdraw my consent and discontinue participation in the Therapy at any time.

PLEASE TYPE "UNDERSTOOD" and your Name (i.e. Understood, Jane Doe)

***Please check off the box to calculate your total then his SUMBIT below**

SOMATIC WOMB TOUCH™1.5 - 2 hours

$98.00CAD

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Somatic Womb Touch ™

Client Confidentiality and Release Form