V Spa Client Intake

V Spa Client Intake Form

The statements and services offered have not been evaluated by the US Food and Drug Administration. This service is not intended to diagnose, treat, cure or prevent any disease. Those seeking treatment for a specific dis-ease should consult a qualified integrative physician, preferably a holistic physician, prior to using our service.

We commit ourselves to the highest standards of integrity and thusly all client information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name *

First Name Middle Name Last Name
Date *

- Month - Day Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date

Month Day Year
Phone Number *
How did you hear about us?

Internet Search (Yahoo, Google, Bing) Facebook Instagram Radio Ad Groupon Referral
E-mail *
Do you wish to join our mailing list? *

Yes No
Do we have your approval to discuss your session information with you via E-mail if necessary? *

Yes No
Primary Care Physician
Phone Number *
Emergency Contact *
History of Pathology

The following questions helps our practitioner to understand your feminine health and womb wellness needs prior to your session.
Has your womb experienced any physical trauma? (check all that apply) *

Sexual abuse Rape Surgeries (hysterectomy, Cesarian, Growth Removals i.e. fibroids, cysts) Injuries Severe Impact or Force None Apply
Do you have a regular menses? ( If yes how often and for how many days? i.e. every 28 days for 4 days max)
Please describe your menstrual cycle
Do you currently have or have had in the past, the following: (check all that apply)

Fibroids Cysts PCOS (Polycystic Ovarian Syndrome) Tumors Endometriosis Amenorrhea ( Absence of Menses) Hypomenorrhea (Short, Scanty Menses) Menorrhagia ( Heavy, Prolonged Menses) Dysmenorhhea (Painful Menses) Hormone Imbalances Adrenal Fatigue PMS Menopause Blood Clotting (during menses) Spotting (between menses) Infertility Feminine Odor Abnormal Vaginal Discharge Genital Itching Miscairrage, Abortion Pregnancy Use of Birth Control
Sexual Health

The following questions give us a better picture of your sexual health. Remember, our goal is to help you to acheive optimal feminine health & womb wellness.
How active is your sexual lifestyle?

Absitinent (not sexually active) Rarely (1-2 times a month) Regularly (2-3 times a week) Hyperactive (3-5 times a day)
Do you experience any of the following? (check all that apply) *

Vaginal Dryness Vaginal Flaccidity (looseness) Inability to Orgasm/Climax Painful Sex Lack of Libido/Stimulation None Apply
All women experience some amount of vaginal discharge. Your normal vaginal discharge helps to clean the vagina, as well as keep it lubricated and free from infection and other germs.

However it's important to recognize the signs of abnormal vaginal discharge because it could be a sign of infection or other serious health condition.
Please describe your vaginal discharge:

Clear, milky, odorless Change in consitency or amount Itching, discomfort, or rash Vaginal burning during urination Presence of blood (bewteen menses) Foul Odor Yellowish, Greyish, or Greenish None Apply
*If you have a vaginal discharge along with any of the aforementioned signs, besides the first option (clear,milky,odorless) we strongly advise that you consult your health care provider for diagnosis and treatment prior to your V Spa appointment.
What are your other health concerns?
What medications (prescribed or over the counter), herbs, vitamins, supplements, etc. are you currently taking?
Please list diseases both prevalent on your maternal and paternal sides of family: (i.e. diabetes, cancer, high blood pressure)
Do you have any known contagious dis-eases at this time? *(If yes, please name in other box) *

Yes No Decline to answer
Do you have a medical diagnosis of any mental, personality, or social disorders? * (i.e. Obsessive Compulsive Disorder, Anxiety Disorder, Hoarding, Schizophrenia) If yes, please name in other box. *

Yes No Decline to answer
Welcome!

My commitment to you as your V Spa Practitioner is to provide a clean, safe, and enjoyable Organic Vagisteam experience. It is important that you understand that V spa and its respective employees does not claim to treat, diagnose, or cure any ilness but offers a gentle herbal hydrotherapy treatment that can be used as a preventative care measure for natural gynecological health.
V Spa Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please drink plenty of water before your appointment

        ( You will be seated on a warm wet-steam sauna chair for approx. 30-50 min. perspiration is to be expected)

       • Please do not consume drugs, medication or alcohol prior to or during the session

       • Please do not to eat at least one to two hours prior to your V Steam session to avoid any ill feelings

       • Do not use any chemicals or lotions prior to your sauna session

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged a $50.00 non-refundable Fee

       • You will be draped in a gown and at no time will genitalia or breast tissue be exposed

       • You will have a 10 min. consultation with your practitioner to discuss your needs and select your

          recommended herbal blend

       • Should the session require, after your Practitioner has left the room, you may adjust chair temperature to

          your comfort level

       • I understand that my V Spa practitioner or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that V Spa and its representatives and employees do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform any gynecological or obsteretic procedures such as papsmeres, ultrasounds, sonograms, cervical or pelvic examinations of any kind.

I acknowledge that herbal vaginal hydrotherapy is not a substitute for medical examination or diagnosis, and it is recommended that a qualified physician be seen for that service.

It is my choice to receive herbal vaginal steam as a form of therapy for my feminine health & wellness.

I understand that treatment given is designed to address the care and prevention of common feminine health issues and womb imablances.

I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my practitoner so they may make necessary adjustments, pause or end the session immediately.

I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless V Spa and its representatives and employees from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Liability Policy:

Here are recommendations for all clients of the V Spa Feminine Health & Womb Wellness Spa. The use of drugs, medication or alcohol prior to or during the sauna session may lead to dizziness or unconsciousness. Please consult your physician if you are in doubt of your ability to use the V Spa Organic Herbal VagiSteam or any of its services for health reasons. Please discontinue the session if you feel light-headed,dizzy or heat exhausted. V steam sessions should be limited to a maximum of 50 minutes. It is advisable to drink plenty of water before and after VagiSteam sessions. It is advised not to eat at least one to two hours prior to your session to avoid any ill feelings. Clients using any medications must consult a physician or pharmacist prior to the use of the serice. We do not provide Organic Herbal VagiSteam treatments to women who are pregnant. Excessive body temperatures have a potential for causing fetal damage ecspecially during the early days of pregnancy. Do not use any chemicals or lotions prior to your session. These items may block pores and affect perspiration as well as stain the (wood) flooring. By checking the agreement box below, I acknowledge and accept the risks inherent in the use of the V Spa Organic Herbal VagiSteam Service. I voluntarily assume the risk of injury, accident or death, which may arise from the use of the V Spa VagiSteam. I and any of my heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal injury or property damages of any kind sustained while in the V Spa, during the use of the VagiSteam and from any advice provided by an employee, independent contractor or any representative. By signing below you agree that this intake form and liability waiver is in effect for all V Spa Organic Herbal VagiSteam Sessions I participate in and will not expire unless requested by either party.
Signature *

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