Surveypoint

Q1

Practitioner Name

First Name

Q2

Practitioner Name

Last Name

Q3

Practitioner Email

Q4

Client Name

First Name

Q5

Client Name

Last Name

Q6

Client Email

Q7

Date

Q8

Indicators for Restore/Cleansing Herbs

Q9

Indicators for Align/Gentle Herbs

Q10

Indicators for Detox/Disinfecting Herbs

Q11

Indicators for Rebalance/Cooling Herbs

Q12

Do You Have Any Food or Plant Allergies?

Q13

Mark All Excess Heat Indicators that Apply

Q14

Do You Have Any Questions or Hesitations Prior to Your Vaginal Steam Session?

Q15

Client Name (Signature)

First Name

Q16

Client Name (Signature)

Last Name

Q17

Signature

Q18

Date of Signature

Q19

Which Setup Would Be Best?

Q20

Yoni Therapy -Form Fill

Practitioner Name

Practitioner Name

Practitioner Email

Client Name

Client Name

Client Email

Date

Indicators for Restore/Cleansing Herbs

Indicators for Align/Gentle Herbs

Indicators for Detox/Disinfecting Herbs

Indicators for Rebalance/Cooling Herbs

Do You Have Any Food or Plant Allergies?

Mark All Excess Heat Indicators that Apply

Do You Have Any Questions or Hesitations Prior to Your Vaginal Steam Session?

Client Name (Signature)

Client Name (Signature)

Signature

Date of Signature

Which Setup Would Be Best?

What Steam Schedule Do You Recommend? (Weekly or 3x Before/After the Period)