Name *

First Name

Last Name

What session are you doing?

Womb Wrap

Yoni Steam

Womb Anointing

Preferred Contact *

Please indicate your preferred method of contact in case of cancellation

Phone

e-mail

Please tick appropriate box;

painful periods

irregular periods

dark thick blood at start of cycle

dizziness with period

headache or migraine with period

excessive bleeding

painful ovulation

failure to ovulate

heaviness or pressure in lower pelvis with period

bloating or water retention

Please tick any other symptoms you are experiencing;

varicose veins in leg

tired weak legs

numb legs & feet when standing still

sore heals when walking

low back ache

painful intercourse

constipation

endometriosis

polycystic ovaries (PCOS)

uterine polyps

fibriods

frequent urination

vaginal discharge

vaginitis

vaginal yeast infections

premature deliveries

Please tick any of the following you are CURRENTLY experiencing

headaches

migraines

ringing in the ears

pins and needles

asthma

loss of smell/taste

skin disorder

swollen ankles

sinus conditions

seizures

sciatica

painful joints

swollen joints

anxiety

spinal problems

fatigue

trouble sleeping

fainting

memory loss

depression

muscle tightness

varicose veins

herniated or bulging disc

high/low blood pressure

Perimenopause & Menopause Symptoms

Please tick the symptoms that apply to you;

hot flushes

insomnia

fatigue

memory loss

mood swings

irritability

dry vagina

depression

spotting

flooding

clotting

irregular periods

increased/decreased libido

Please read and then submit your form *

By ticking this box, I am declaring that: - I understand that payment is due at the time of booking my treatment unless arrangements have otherwise been made. - Cancellations within 24 hours of the session will be charged in full. Cases of extreme emergency are considered exceptions to this policy. - I understand the treatment here is not a replacement for medical care. - I understand the therapist does not diagnose medical illness, disease or any other physical or mental conditions. - As such, the therapist does not prescribe medical treatment of pharmaceuticals, nor does she perform any spinal manipulations. - I have stated all my known conditions and take it upon myself to keep the therapist updated on my health.

Tick as signed declaration