The Fresh Yoni, LLC V-Steam Intake Form

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DISCLAIMER: Services provided by The Fresh Yoni, LLC are not meant to act as a medical substitute, does not take the place of, nor should be used to replace those provided by a physician or specialist (including, but not limited to the vaginal steam and detox services), nor are we able to diagnose or cure serious vaginal issues. When you receive a service you are agreeing to be fully responsible for your own health, and consider the provider free of any legal responsibility. The Fresh Yoni, LLC assumes NO responsibility for any adverse allergic reactions from products used while providing services, neither assumes ANY accountability for a miscarriage due to your deceit or lack of knowledge about pregnancy, or the loss of an IUD.

DISCLOSURE: All information provided to The Fresh Yoni, LLC is confidential and will not be shared with anyone.

The State of Ohio mask mandate for COVID-19 has been relaxed. Our business establishment is concerned about the health and safety of our customers. We follow OSHA standards for the sanitation and cleaning of our facility. Please note that currently, wearing a mask is OPTIONAL. However, if the mask mandate is ever reinstated you agree to abide by the MANDATORY requirement. *

Yes

Required

First & Last name *

Email address *

Cell phone number *

What is your current age? (Under 18 must be accompanied by or given prior parental/guardian consent) *

Under 18

18-21

22-25

26-30

31-35

36-40

41-45

46-50

51-55

55+

Required

List any known allergies to herbs. If none, respond not applicable (N/A) *

Do you still have a menstrual cycle? (Note: You cannot steam during menstruation) *

Yes

Menopausal

Required

Describe the problems you experience during menstruation or menopause. *

What is the reason for your visit today? Check all that apply. *

Reducing Menstrual Symptoms

Reducing Yeast Infections

Treating Fibroids

Treating Hemorrhoids

Increasing Energy

Increasing Libido

Treating Headaches

Treating Vaginal Dryness

Required

For the health & safety of ALL customers and Staff we need to know if you have any of the following: *

A Vaginal Infection

A Sexually Transmitted Disease (STD)

HIV/AIDS

None of the above

If you're on birth control which type do you currently use other than a condom? (If IUD you can only steam for 10 minutes) *

Pill

Implant

Shot

Ring

Patch

IUD

N/A

Required

Are you pregnant now, or have you had a baby less than eight weeks ago? *

Yes

Which V-Steam package or Foot Soak service are you interested in purchasing? (what's included) *

Goddess Package ($35)- 30 minute Herbal V-Steam, Detox Tea & Detox Foot Pads (water, wine, healthy snack & treats)

Queen Package ($55)- 30 minute Herbal V-Steam, Detox Tea & Detox Foot Soak (water, wine, healthy snack & treats)

Empress Package ($75)- 30 minute Herbal V-Steam, Detox Tea & Ionic Foot Soak (water, wine, healthy snack, treats)

VIP Diva Package ($30 @= $60)- Two Goddess V-Steam Packages per month paid in advance (see description above) {ADD a Detox Foot Soak for $10 & use the Foot Detox Pads at home}

Foot Detox Soak ($20)- 20 minute herbal detox foot soak (water, detox tea, healthy snack)

Ionic Foot Soak ($30)- 30 minute heavy metals detoxifying foot soak that can boost your immune system (water, detox tea, healthy snack)

List any known food allergies to fruits, nuts, chocolate, etc. If none, respond not applicable (N/A) *

How did you find out about The Fresh Yoni, LLC? *

Facebook

Instagram

Word of mouth

Other:

Required

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