Indigemama Client Intake Form

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Name (First, Last) *

 
Email *

 
Date of Birth *

 
Height *

 
Weight *

 
Build/Body type *

 
Phone Number *

 
Address OR City *

 
Primary reason(s) for coming in: *

 
What is your level of discomfort on a scale of 1-10. 1 being little to no discomfort, and 10 being great discomfort. *

 
Would you like to use this email address to sign up to Indigemama's free Newsletter? *

     
 
Occupation *

 
Referred by *

 
Emergency Contact *

Please include name, address, relationship and phone number
 
Have you had a womb massage (sobada) before? *

 
Do you have any difficulty lying on your front, back, or side? *

 
Have you had surgery or mechanical, emotional, or sexual traumas at all?  Any in the last 6 months? *

Please list below.
 
Are you in your first trimester of pregnancy or menstruating? *

Do not schedule a session if yes.
 
Do you have any allergies to oils, lotions, ointments, fruits or nuts? *

 
Are you currently under medical supervision? *

 
Do you have active cancer? *

 
Do you currently use an IUD, Coil, Ring, or any other form of internal birth control? *

     
 
Are you currently taking any medication?  If so, please list. *

     
 
Please share anything else about your health history that you think would be useful for your Mesoamerican womb massage practitioner to know to plan a safe and effective massage session for you? *

 
What is your womb story? Any other goals, intentions, or thoughts you'd like to share? *

 
I understand that the care I receive is provided for the basic purpose of relaxation and relief of muscular tension.  I understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician other qualified medical specialist for any mental or physical ailment that I am aware of.  I understand that massage therapists are not qualified to perform diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.  Because womb massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.  I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. *

     
 
Client Informed Consent Form *

Indigemama: Ancestral Healing provides alternative, complementary health care in the field of Mexican Traditional Medicine (MTM), Indigenous and Western herbalism, holistic health, meditation, energy work, Mesoamerican Womb Massage (sobadas) and other branches of Classical Mesoamerican and MTM. Classical Mesoamerican and Mexican Traditional Medicine involve a cooperative process and it is essential for practitioners and clients to work towards the same objective.

The objective of Indigemama: Ancestral Healing is to identify and address patterns of imbalance in order to support a state of balanced feminine health.  Health and your womb within this theoretical framework of MTM and energy work is achieved through sobadas (womb massage and adjustments), limpias (energy clearings), herbalism, nutritive foods, a harmonious relationship with nature, fulfilling your life purpose or role in society, meaningful interactions with others, mental and emotional stability and a balance between the physical substances and physiological processes of the body, namely your womb.  

Your emotional and physical womb are in a continually adapting, shifting state of balance. All transformations, rites of passage, movements within the body (physical or emotional), and life experiences directly impact your womb wellness. Panquetzani is here to provide guidance, resources, information and inspiration during these processes.

Indigemama: Ancestral Healing is owned and operated by Panquetzani Macuilcoatl (Kimberly Mercado) as sole proprietor. Panquetzani is an experienced practitioner, having learned traditionally, through apprenticeship. She has safely served more than three thousand women in two dozen different cities using MTM and Mesoamerican Womb Massage. Panquetzani is not an MD, Physician, or Surgeon, and is not licensed by the State.  She does not diagnose or treat medical conditions. She may address patterns of imbalance in order to support an adaptable state of balanced health within the individual.

I have read and understand the above statements. I therefore accept care from Indigemama: Ancestral Healing on this basis.

*Please keep this copy in your records for three years.
     
 
Cancellation Policy *

*Cancellations must be made 24 hours prior to appointment time or you will be charged in full.

     
 
Address

Mondays and Wednesdays:
Sacred Roots
316 Redondo Ave. Long Beach, CA 90814

Tuesdays:
SOHMA Integrative Health Center
4195 N. Viking Way, Suite F Long Beach, Ca 90808
(Unless otherwise noted)

 
How to Prepare:

1.  Wear loose, comfortable clothing (or you can take them off)
2.  Prepare to abstain from alcohol, drugs, lifting heavy things, or having penetrative sex for three days following your sobada.
3.  Don't over eat or have a heavy meal within 20 minutes of arriving. Some clients may be asked to fast on bone broth.
4.  Bring a rebozo (optional), and I'll tie your faja, gratis. :)

 
Please contact your healthcare provider before starting any health care regimen. In emergency, call 911.

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