Honey Pot Intake Form
2720 Sheraton Dr. Building D. Suite 250
Macon, GA 31204
478-216-3166
There are times when it is not beneficial for a women to steam. First, let's check and make sure that you don't have any contraindications. Please answer the following questions to the best of your ability.
Email *
Name *
Email & Contact number *
Are you on your menstruation? *
Do you currently have fresh spotting? *
Do you ever have two periods per month? *
Do you have spontaneous bleeding? *
Do you have an infection characterized with a burning itch? *
Are you pregnant? *
If you trying to conceive are you past ovulation? *
Do you have tubal coagulation burning of the fallopian tubes (through laparoscopic surgery) *
Do you have a birth control arm implant (i.e. Nexplanon)? *
Some women are very responsive to steam and it can cause a physiological response. If you are in this category then it is okay to steam, however your practitioner will adjust your steam session and herbs so that it perfectly suits you. *
Is this your first time doing a yoni steam session? *
Are your menstrual cycles currently or historically ever 27 days or shorter? *
Have you experienced any night sweats over the past month? *
Do you have an IUD in? *
Are you currently or historically prone to yeast infections? *
Are you currently or historically prone to bacterial vaginosis? *
Do you have herpes? *
Do you have the nuva ring in? (If so, it should be removed prior to steam session) *
Are you age 13 or younger? *
Do you have hot flashes, night sweats or an aversion to heat? *
WAIVER: Most of the side-effects reported while steaming are positive. Users have reported better sleep, decreased swelling in legs and feet, decreased abdominal bloating, increased libido, fewer PMS symptoms, increased energy, lucid dreams, tingling feet, glowing skin, increased lubrication. However, some undesirable side effects might also occur. These include shortened menstrual cycles, onset of bleeding, headaches, the sensation to urinate or an infection outbreak. In 99% of all cases using a mild steam session and mild herbs will prevent the above from happening so it's very that you give honest answers in this intake form so that the practitioner knows the proper safety standards regarding setting up a yoni steam session tailored to fit your needs. PLEASE INITIAL BELOW AFTER READING: *
Please sign your name below when you have completed and read the waiver. I understand that yoni steaming may have positive or negative side effects as a result of doing vaginal steam session. I accept legal responsibility for my choice to do a vaginal steam session and waive the responsibility of the practitioner and the facility where the steam session takes place in the case that any of the names side effects (or others) may occur. *
Date Completed: *
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COVID-19 AGREEMENT
I knowingly and willingly consent to have vaginal steam during the COVID-19 pandemic. I understand that the COVID-19 virus can have a long incubation period, during which carriers of the virus may not show symptoms and can still be highly
contagious. I confirm that I am not presenting any of the following symptoms of
COVID-19 listed below:
• Fever temperature over 99.6°F
degrees
• Chills with or without body aches
• Shortness of breath
• New loss of sense of taste or smell
• Unexplained sores on soles of feet
• Unusual fatigue
• Cough
• Sore throat
Please seek immediate medical attention if you are displaying any severe signs of COVID-19.
I confirm that I have not been in close contact with anyone exhibiting the above
COVID-19 symptoms within the past 14 days. I further confirm that I am not currently living with anyone who is sick or who is quarantined. To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the
therapist’s guidelines.

Signature: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Date: ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
(Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your Doctor that may impact the
above release statement.)
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