Client Intake Form

This Intake form must be filled out and accepted in order to receive any services at Queen Bee Yoni Pot Spa.  If you need additional information or have questions feel free to contact us and we will gladly assist.

Emergency Contact

Reason for Visit

There are times when it is not beneficial for a woman to steam. First, let's check and make sure that you don't have any of the contraindications:

Important: The above “Yes” replies indicate that vaginal steaming in contraindicated. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not be performed at this time.
When Yoni steams should be avoided:
  • If you are pregnant or there is a possibility of pregnancy
  • During or after ovulation if you are trying to conceive
  • During menstruation
  • Fresh spotting or spontaneous bleeding
  • With any open wounds, sores, blisters or stitches
  • If you have a vaginal infection or fever
  • Piercings will need to be removed
  • Birth control implant (Nexplanon, Implanon)
  • Infection with burning
  • Tubal Coagulation

  • If you have an IUD, Yoni steams help release matter from the IUD. Steaming is not recommended.

Reproductive Health History
If you are using the above birth control methods vaginal steaming could cause a birth control failure. It is not recommended unless you are okay with a backup form of birth control or you are not concerned about a possible pregnancy.  If you have a burning itch the warmth from the steam could be uncomfortable since there is already so much heat in that area. In this case it is best to seek treatment from an acupuncturist to get the burning sensation to go away prior to doing a vaginal steam session.

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.

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, yoni steam baths may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner so that the temperature may be adjusted to my level of comfort. I further understand that yoni steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a medical provider, or other qualified medical specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the yoni steam bath is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Vaginal/yoni steam baths should not be performed under certain medical conditions. I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand . that there shall be no liability on the practitioner's part should I forget to do so. I am aware and I understand there is a possibility that my IUD can be released due to a Yoni Steam Bath. This has been explained to me and I am to proceeding with the Yoni Steam Bath at my own risk.

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Please do not complete a Client Intake form if you have not booked an Appointment. Go here to Book Appointment Here.