Yoni Steam Consent Form

Full Name

Phone Number

Date of Birth

Address

Emergency Contact Name

Emergency Contact Phone

What is your health history?

Please check all that apply to you:

Is this your first time doing a yoni steam?

Do you have hot flashes or night sweats?

Do you have an IUD?

Are you pregnant or trying to become pregnant?

Are you currently or historically prone to yeast infections?

Are you currently or historically prone to bacterial vaginosis?

Are you currently or historically prone to urinary tract infections (bladder infections)?

Do you have herpes?

Do you have the nuva ring in? (If so, it should be removed prior to steam session)

Do you have a history of spontaneous bleeding or two periods per month (3 months or later in the past)?

Are your menstrual cycles 28 days or longer?

Is your menstrual cycle absent or missing for an unknown reason or because of birth control?

Are you currently taking birth control pills?

Do you ever have menstrual cycles 27 days or less?

Do you have fresh spotting between periods?

Are you currently under age 13?

Do you have green vaginal discharge?

Do you have yellow vaginal discharge?

Do you have white vaginal discharge?

Do you have thick vaginal discharge

Do you have malodorous vaginal discharge?

Do you have vaginal dryness?

Do you have any type of dry vaginal infection (without vaginal discharge)?

Do you have an aversion to heat?

Are you prone to vaginal infections or viruses?

Do you have any plant or food allergies? (please describe)

If you no longer have a period, what is the reason? (please describe)

What to Expect: Steaming is a cleanse. Some of the possible signs vaginal steaming is working is if you experience the following: urination urge while steaming, brown discharge after steaming, increased clots or cramps during your next period, increased dry cramps, increased irregular vaginal discharge (white, green, thick, clumpy), emotional release, periods that come earlier or later than expected. All of these signs are a normal part of the cleansing process and these signs should go away once the cleanse is complete. Please note these changes and inform your provider.

Best Practices:

Go to the bathroom directly prior to vaginal steaming.
Bring a pad for possible discharge after the steam.
Learn proper periods care: avoid tampon use and instead use cotton pads or period panties. The period is a uterine cleanse and if you support it, the clots can easily clear out. Plugging up with tampons prevents the old residue from clearing out and is often the cause of additional cramping. It is also important to rest, be gentle with yourself, and eat foods that support and nourish you.

I have purchased or am receiving complimentary steaming services, products or a consultation from Company (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 Lotus Counseling and Wellness Center or its agents. I further affirm, that all information provided to Lotus Counseling and Wellness Center 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 Lotus Counseling and Wellness Center premises that is not used as part of the Services, I expressly agree that I will not use the equipment and release Lotus Counseling and Wellness Center, 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 affirm that I have confirmed on www.steamychick.com that Lotus Counseling and Wellness Center’s practitioner has a vaginal steam specialist certification.

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.

Lotus Counseling and Wellness Center, 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 Lotus Counseling and Wellness Center, 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 Lotus Counseling and Wellness Center, 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 Lotus Counseling and Wellness Center 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 Kentucky 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.

Consent Agreement

Signature