Postpartum Vaginal Steam Waiver

Postpartum Vaginal Steam Waiver

Muriel Webster Vaginal Steam Facilitator Certified by:The Peristeam Hydrotherapy Institute
Client's Name

First NameLast Name
Client's Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date did you give birth?

MonthDayYear
Date
I am interested in:

In-Home TreatmentSatellite ConsultationPostpartum Steam Package
After birth there is post-delivery discharge. This discharge is called lochia and it varies from day to day after birth and can be an important indicator for your recovery. Does your current lochia have the following characteristic?
Heavy (Soaking more than 1 pad per hour)

YesNo
If so, please provide more information. Is it still heavy or has it slowed down?
Does the lochia have any of the following characteristics?

Medium FlowLight FlowGoes away, then comes backPostpartum ContractionsRed in ColorPink in ColorWhite in ColorBrown in Color
Additional Notes:
Delivery Side-Effects

HemorrhoidsSwollen SkinProlapseWater RetentionDifficult UrinationBladder IncontinenceConstipationTear + StitchesTear, no StitchesEpisiotomy, Stitches
Additional Notes:
Do You Have Any of the Following Infections or Heat Signs?

HerpesYeast InfectionBacterial InfectionsUrinary Tract InfectionMalodorous LochiaYellow LochiaFeeling FeverishNight SweatsHot Flashes
Additional Notes:
Do You Have Any of the Following Uterine Fatigue Signs?

History of Short Menstrual Cycles (27 days or shorter)Did Labor Start Naturally Prior to 39 Weeks?Did You Have Any Fresh Spotting During the Pregnancy?Has the period returned before 9 months postpartum?Are you 30 days after giving birth and continue to have lochia that is fresh blood - not brown?
Additional Notes:
What Vaginal Steam Supplies do You Already Have?

Vaginal Steam SeatVaginal Steam HerbsOther SetupNone of the Above
Do you have any questions or hesitations prior to your vaginal steam session?
Have You Done Any Postpartum Vaginal Steaming Yet? If so, what results have you noticed? What is it helping with? Any other areas that still need to be addressed?
Most of the side-effects reported while steaming are positive. Users have reported relief of delivery side effects, more breastmilk, better sleep, decreased swelling in legs and feet, decreased abdominal bloating, slimmer waistline, decrease in breast soreness, fewer headaches, fewer PMS symptoms, increased energy, lucid dreams, tingling feet, glowing skin, reduction in incidence of hormonal acne and relaxation.

However, some undesirable side effects might also occur. These include onset of bleeding, headaches, the sensation to urinate or an infection outbreak. In 99% of all cases using a mild steam session and mild herbs will prevent the above from happening so it's very important that you give honest answers in this intake form so that the practitioner can set up a steam session that will fit your needs.

Note: It is best practice to check that your vaginal steam specialist has a vaginal steam certificate in good standing. This certification ensures that your practitioner knows the proper safety standards regarding setting up a vaginal steam session tailored to fit your needs. Please check the Vaginal Steam Directory (www.vaginalsteamdirectory.com) to ensure that your practitioner has a valid certificate. The Peristeam Hydrotherapy Institute keeps an up-to-date list of all certified practitioners on the directory so if they are not on the map it's possible that the certificate is fabricated.

I understand that vaginal steaming may have positive or negative side effects as a result of doing a session. I accept legal responsibility for my choice to do a vaginal steam session and waive the responsibility of the practitioner and the facility where the steam session takes place in the case that any of the named side effects (or others) may occur.
Signature

Clear
Date

MonthDayYear
Date
PRACTITIONER USE ONLY
Which setup will be best? (Herbs, Duration, Cloaking)
If more than one herbal blend is indicated, how should they be used?
Recommended Length of Protocol
Should be Empty: