Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
Address
*
To ensure full comfort during my steam, I will not apply body lotions, oils, or creams to my skin prior to my appointment.
*
Yes, I will not apply body lotions, oils, or creams to my skin prior to my yoni steam.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
To ensure full comfort during my steam, I will not shave or wax prior to my appointment.
*
Yes, I will not shave or wax prior to my yoni steam.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
To ensure full comfort during my steam, I will remove any vaginal piercings prior to my appointment.
*
Yes, I will remove any vaginal piercings prior to my yoni steam.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
I will dress comfortably to participate in gentle stretching before sitting on the yoni pot.
*
Yes, I will dress appropriately for gentle stretches prior to my steam.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
VAGINAL STEAMS ARE NOT PERFORMED DURING PREGNANCY. Please confirm you are not pregnant.
*
Yes, I confirm I am NOT pregnant.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
VAGINAL STEAMS ARE NOT PERFORMED WHILE BLEEDING OR SPOTTING. Please confirm you are not bleeding or spotting.
*
Yes, I confirm I am NOT bleeding or spotting.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
Have you ever experienced a yoni steam?
*
Yes, I do them at home.
Yes, at another wellness center.
No, this is my first time.
I understand the room will be slightly heated to aid herb absorbancy and comfort. I will hydrate accordingly before the session, and have adequate water available during my yoni steam.
*
Yes, I will ensure proper hydration.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
I understand yoni steaming is a sacred ancestral practice. I will maintain a state of reverence and honor during my experience.
*
Yes, I honor this sacred practice.
No, I am not willing to comply and therefore not ready to receive services from Viktorious Mama.
Date of Last Menstrual Cycle
*
MM
DD
YYYY
Date of Menopause Beginning (if applicable)
MM
DD
YYYY
List any vitamins/herbal supplements you are currently taking.
*
Are you steaming for fertility? (are you trying to get pregnant?)
*
Yes,
No
Indicate all that your vagina has experienced (check all that apply)
*
Check all that apply:
*
Current Contraceptive Method
*
Check all that apply:
*
Check all that apply:
*
Check all that apply:
*
Primary Care Physician
*
Do you currently speak to a therapist, priestess, or alternative professional provider?
*
Yes
No
Check all that apply:
*
I hereby state that all of the information in this form is accurate and true to the best of my knowledge. I shall immediately update the form with any changes as I am made aware of them.
*
I do.
I hereby state that I am not representing any other person, company, association, or agency. All information submitted pertains to me.
*
I do.
I hereby state that I fully consent to participation in the yoni steam and accept any risks inherent (if any) in my engagement of such activities.
*
I do.
I release Kayla Anderson and Viktorious Mama from any claims implied or stated, that I have or may have in the future with this treatment, regardless of the results. I agree that my completion of this form serves as my waiver and will not expire. I understand I am free to withdraw my consent and stop services at any point. I understand there is a no refund policy.
*
I do.
