Indigemama Workshop Registration Form
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Name (First, Last) *

 
Email *

 
Phone Number *

 
Date of Birth *

 
What is your preferred gender pronoun? *

 
Occupation *

 
Referred by *

 
County or City of residence *

 
How did you hear about this event? *

 
Which Workshop are you enrolling in?


 
Workshop is to be held in:


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

     
 
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 private sobada if yes.
 
Do you have any allergies to oils, lotions, ointments, fruits or nuts? *

 
Are you a nursing mother? *


 
Are you currently under medical supervision? *

 
Do you have active cancer? *

 
Do you have any concerns, issues or previous medical problems regarding your reproductive organs? *

 
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. *

     
 
What type of experience, practices, study, or interests have you had in natural healing? *

 
What do you expect to learn? *

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

 
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.

     
 
A part of Indigemama's work is to share information and inspire others in education and self-care. Do you agree to be filmed or photographed for use on social media or Indigemama's website? *


 
By attending this workshop, I agree not to reproduce, share workshop materials, or any information provided to me during this workshop. I understand Indigemama does not assume any liability for misuse of any of the information learned during this workshop. *


 
Please Bring:

Saturday
A notepad and pen or laptop (Sat-Sun)
Personal canteen, mug, plate and silverware to reduce paper waste
Comfortable clothing (may get oily)Yoga mat or blanket for laying and sitting (Sat-Sun)
A glass jar, medium to large-sized (to store castor pack)
A rubber water bottle, heat pad or rice sock (for abdominal area)
A nursing blanket, old t-shirt, or flannel fabric for castor pack
A simple dish for communal meal (pre-made), preferably enough for 15
Rebozo (encouraged Sat and Sun)
Towel

Sunday
A simple dish for communal meal (pre-made), preferably enough for 15
Large pot or large soup bowl (clay, porcelain, glass, and other natural materials only) for vaginal steaming
Blanket that covers your entire body (head to toe)
Towel

Optional
Item(s) for the altar (something you work with, use for healing, has personal/cultural significance)
Fresh or dried organic herbs/plants/seeds to share
Any offering for the space, host, facilitators or fellow participants to keep
A large skirt for vaginal steams (highly recommended Sunday)

 
Emergency Contact *

Please include name, address, relationship and phone number
 
Please contact your healthcare provider before starting any health care regimen. In emergency, call 911.

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