WOMB THERAPY ENDEED FORM
The statements and services offered have not been evaluated by the US Food and Drug Administration. This service is not intended to diagnose, treat, cure or prevent any disease. Those seeking treatment for a specific dis-ease should consult a qualified integrative physician, preferably a holistic physician, prior to using our service.
FULL LEGAL NAME
FACEBOOK/TWITTER/IG USER NAME
SEVER IMPACT OR FORCE
PHONE NUMBER, ADDRESS AND EMAIL
DATE OF BIRTH
PREFFERED METHOD OF CONTACT IN BETWEEN SESSION
MAY WE ADD YOU TO OUR EMAIL DISTRIBUTION LIST
FOR UPCOMING EVENTS, DISCOUNTS ECT
DO YOU HAVE A REGULAR PERIOD?
IF SO HOW LONG, HOW MANY DAYS AND COLOR (DARK RED, PURPLE ECT) I.E EVERY 21 DAYS FOR 5 DAYS
PLEASE LIST DISEASE PREVALENT ON BOTH MATERNAL AND PATERNAL SIDE OF FAMILY
I.E DIABETES, HIGH BLOOD PRESSURE, CANCERS
DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING
CHECK ALL THAT APPLY
POLYCYSTIC OVARIAN SYNDROME (PCOS)
CLOTTING DURING PERIODS
PERIODS LONGER THAN 4 DAYS
SEXUALLY TRANSITMITTED DISEASE
DEATH OF CHILD
USE OF BIRTH CONTROL
USE OF ANTIBIOTICS
SPOTTING IN BETWEEN PERIOD
DO YOU HAVE ANY OTHER HEALTH CONCERNS
PLEASE LIST IN ORDER OF SEVERITY
WHAT MEDICATIONS PRESCRIBED OR OVER THE COUNTER, HERBS, VITAMINS, SUPPLEMENTS ECT ARE YOU CURRENTLY TAKING
ALSO LIST WHAT YOU ARE TAKING THEM FOR
WHO IS YOUR PRIMARY PHYSICAN
DO YOU HAVE ANY MEDICAL DIAGNOSIS OF ANY MENTAL , PERSONALITY OR SOCIAL DISORDERS?
OBESSIVE COMPULSIVE DISORDER, ANXIETY DISORDER, HOARDING, SZCHOPHRENIA
DO YOU HAVE ANY KNOWN CONTAGIOUS DISEASE AT THIS TIME
IF YES NAME PLEASE LIST
HOW DID YOU HEAR ABOUT THE WOMB THERAPY ENDEED? IF REFERRERED PLEASE LEAVE NAME BELOW.
WOMB THERAPY ENDEED LIABILITY POLICY
Here are recommendations for all clients of the Womb Therapy Endeed. The use of drugs, medication or alcohol prior to or during the steam session may lead to dizziness or unconsciousness. Please consult your physician if you are in doubt of your ability to use the Womb Therapy Endeed for health reasons. Please discontinue the use of the steam if you feel light-headed, dizzy or heat exhausted. Womb Therapy Endeed sessions should be limited to a maximum of 60 minutes. It is advisable to drink plenty of water before and after steam session. It is advised not to eat at least one to two hours prior to your steam session to avoid any ill feelings. Clients using any medications must consult a physician or pharmacist prior to the use of the steam. Pregnant women should consult their physician prior to the use of the steam. Excessive body temperatures have a potential for causing fetal damage during the early days of pregnancy. Do not use any chemicals or lotions prior to your sauna session. These items may block pores and affect perspiration. By checking the agreement box below, I acknowledge and accept the risks inherent in the use of the Womb Therapy Endeed. I voluntarily assume the risk of injury, accident or death, which may arise from the use of the Womb Therapy Endeed. I and any of my heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal injury or property damages of any kind sustained while in the Womb Therapy Endeed, during the use of the Womb Therapy Endeed and from any advice provided by an employee, independent contractor or any representative. I agree that this intake form and Waiver is in effect for all Womb Therapy Endeed sessions and will not expire unless requested by either party.
ENTER YOUR NAME IN THE BOX BELOW YOU HEREBY AGREE TO THE ABOVE TERMS *
A copy of your responses will be emailed to the address you provided.
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