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Yoni Steam Consent

Allure Body and Wellness is commited to providing exceptional service in a timely manner. Unfortunately when a customer cancels without giving notice, it prevents other customers from being served. For those purposes, Allure Body and Wellness has implemented a cancellation policy that will be strictly observed. 

Cancellation and/or rescheduling requests may be submitted by phone or email. We can be reached at (267) 490-7403 or allurebodyandwellness@gmail.com. We respectfully ask that you make contact within 24 hours of your scheduled appointment time. Your $25 deposit is non-refundable and can only be used once towards a rescheduled appointment after cancellation or a no show. If a secondary no call no show were to occur,  you surrender your intial deposit and must pay another deposit to schedule a new appointment.   

 

Yoni Steam Contraindications

Yoni Steams should be avoided if:

  • You are pregnant or maybe pregnant 
  • Your appointment is during or after ovulation and you are trying to get pregnant
  • Are currently on your period
  • You have had spontaneous bleeding within the last 3 months
  • You have had an irregular period in the last 3 months
  • You have had a vaginal procedure in the last 3 months
  • You have any open wounds, sores, blisters or stitches
  • You have any kind of vaginal infection
  • You have tubal ligation

 

If you have any of the above listed contraindication a Yoni Stean cannot be performed at this time.

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical History

When was the first day of your last period?

How often do you get your period?

How long do your periods last?

Do you have any concerns with your menstrual cycle?
Are you currently receiving treatment for infertility?*
Yes
No
Are you currently pregnant or maybe pregnant?*
Yes
No
Are you currently on birth control?*
Yes
No

If so, please list your birth control?
Are you currently experiencing any vaginal discomfort?*
Yes
No

If so, please explain?
Do you currently have a STD?*
Yes
No
Do you currently or are you prone to vaginal infections?*
Yes
No
Do you suffer from vaginal dryness?*
Yes
No
Do you have allergies?*
Yes
No

If so, please list all allergies?
Are you currently taking medication?*
Yes
No

If so, please list medication?
Do you have any of the following:
Heart disease
Hypertension
Hypotension
Hyperthyroidism
Blood disorder
Diabetes
Cancer
Parkinsons
Lupus
Adrenal suppression
Multiple Sclerosis
Is this your first yoni steam?*
Yes
No
Photos
Do you give Allure Body and Wellness permission to take before, during, and after photos?*
Yes
No
Do you give Allure Body and Wellness permission to use your photos taken during your session for the purposes of advertising, promoting, and education?*
Yes
No
Consent
I understand that if I experience any pain or discomfort, I will immediately inform the practitioner.*
Yes
No
I understand that yoni steams should not be construed as a substitute for medical examination, diagnosis or treatment.*
Yes
No
I understand that the practitioner facilitating the yoni steam is not qualified to diagnose, prescribe and/or treat any physical or mental illness and nothing being said during the course of any session should be construed as such.*
Yes
No
I have elected, by my own decision to have a yoni steam performed.*
Yes
No
The procedure, including the process and objective has been explained to me before undergoing the yoni steam procedure.*
Yes
No
I understand and acknowledge any risks or complications associated with the procedure as they have been explained.*
Yes
No
I have been given the opportunity to ask questions regarding benefits, risks, or possible complications of the procedure.*
Yes
No
I understand that there are no guaranteed results and that my results may vary from others.*
Yes
No
I confirm I have given an accurate account of my medical history, including any allergies, diseases, and medications.*
Yes
No

With my signature below, I confirm that I have read fully and understand the information in this consent form and all details it includes. I have provided an accurate account of my medical history including any medications I take and any medical procedures I intend to undergo. By signing below, I agree to accept all and full responsibility for any risks, injuries, damages, or side effects that may occur as part of the procedure. I will not hold my practitioner and/or Allure Body and Wellness responsible.

This authorization will remain in effect until revoked by the patient in writing.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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