Womb & Pelvic Healing Intake & Release Form

Contact Information
Today's Date
Today's Date
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Their name, your relationship to them and their phone number
Intention-Setting
What do you attribute this to?
All About Your Cycle
Date of Last Period
Date of Last Period
Average day of cycle (for example 28 days). If irregular, note how they are irregular here.
If so, what size and color?
If so, how do you experience it?
Reproductive History
Y/N If so, what kind?
Y/N Feel free to discuss any changes you may notice.
Reproductive Symptoms
In order to best formulate your herbal steam blend, please check any that apply.
I am aware of the contraindications of various modalities that may be practiced listed below. By signing this form, I agree that they do not currently apply to me. You should NOT receive Maya abdominal massage, Holistic Pelvic or a vaginal steam if any of the following apply: Arvigo Techniques of Maya Abdominal Therapy: Deep abdominal massage will not be performed if: ❂ You have an IUD ❂ You’re currently menstruating ❂ You’re pregnant ❂ You’re currently miscarrying ❂ You’re trying to conceive and have already ovulated Holistic Pelvic Care: Internal pelvic floor work will not be performed if: ❂ You’re pregnant ❂ You’re currently miscarrying ❂ You’re trying to conceive and have already ovulated ❂ You have a history of severe trauma that has not received counseling Herbal Pelvic Steams: Vaginal steam baths will not be performed if: ❂ You’re pregnant ❂ You're currently menstruating ❂ You’re currently miscarrying ❂ You’re trying to conceive and have already ovulated ❂ You have a history of severe trauma that has not received counseling ❂ You’re prone to spontaneous, heavy bleeding Use caution if: ❂ You have an IUD, as this carries a small but possible risk of expelling the IUD
Please take a moment to carefully read the following information and sign by typing your initials below. If you have a specific medical condition or specific symptoms, any of these modalities may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner. Additionally, if I am receiving a vaginal steam bath, I will let the practitioner know if the heat is too hot so that the temperature may be adjusted to my level of comfort. I further understand that these modalities should not be construed as a substitute for medical examination, therapy, diagnosis, or treatment and that I should see a physician, therapist or other qualified medical or counseling specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the healing is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because each of the above named modalities should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so. I am aware and I understand there is a possibility that my IUD can come out due to a Maya Abdominal Therapy session or a Vaginal Steam Bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk. I understand that I am proceeding to receive any of these healing modalities at my own risk and hereby release Jeevan Singh from any liability.