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Please tell us about your body today.

CUPPING DISCLOSURE & CONSENT

Your massage therapist utilizes every available means, including written and verbal intake, and visual and tactile clues in order to give a safe and effective treatment.

Massage Cupping is a therapeutic decompression technique used by massage therapists, acupuncturists and bodyworkers for the relief of muscular pain, tension, and congestion. These techniques are used to draw out congested fluids and toxins to the surface tissue layers, allowing for fresh blood and lymph circulation. The resolution of stagnation and granulation in the tissues often brings an immediate relief from pain.

Massage Cupping uses negative pressure created within a specialized glass or rubber cup that is applied to the affected body part. The pressure can be deep to provide relief from tension, pain and injuries. Gentler pressure increases lymph flow, circulation and relaxation, and is excellent for facial treatments. 

There​ ​is​ ​a​ ​possibility​ ​of​ ​discoloration​ ​that​ ​can​ ​occur​ ​from​ ​the​ ​release​ ​and​ ​clearing​ ​of​ ​stagnation and​ ​toxins​ ​from​ ​the​ ​body.​ ​The​ ​reaction​ ​is​ ​not​ ​bruising,​ ​but​ ​the​ ​cellular​ ​debris,​ ​pathogenic​ ​factors and​ ​toxins​ ​being​ ​drawn​ ​to​ ​the​ ​subcutaneous​ ​layers​ ​for​ ​dissipation​ ​by​ ​the​ ​circulatory​ ​system.​ ​The discoloration will​ ​dissipate​ ​in​ ​as​ ​soon​ ​as​ ​a​ ​few​ ​hours​ ​or​ ​up​ ​to​ ​1​ ​week,​ ​and​ ​in​ ​relation​ ​to after-care​ ​activities.​ ​It​ ​is​ ​important​ ​to​ ​drink​ ​plenty​ ​of​ ​water​ ​to​ ​stay​ ​hydrated,​ ​and​ ​avoid​ ​vigorous exercise​ ​for​ ​24​ ​hours​ ​after​ ​treatment.

Cupping​ ​should​ ​NOT​ ​be​ ​performed​ ​with​ ​any​ ​of​ ​the​ ​following​ ​conditions​ ​present, please​ ​communicate​ ​to​ ​your​ ​practitioner​ ​should​ ​any​ ​of​ ​these​ ​conditions​ ​be​ ​present​ ​for​ ​you:

>You​ ​are​ ​taking​ ​blood​ ​thinning​ ​medications
>On​ ​a​ ​recent​ ​injury
>On​ ​any​ ​skin​ ​conditions:​ ​sunburn,​ ​eczema,​ ​dermatitis,​ ​rashes,​ ​ulcerated​ ​skin​ ​or​ ​skin​ ​that​ ​lacks integrity
>Areas​ ​that​ ​lack​ ​sensation​ ​or​ ​are​ ​numb
>Cold​ ​or​ ​flu-like​ ​symptoms
>You​ ​have​ ​low​ ​blood​ ​sugar/empty​ ​stomach 

I Agree

Post​ ​treatment:

Avoid​ ​exposure​ ​to​ ​extreme​ ​temperatures,​ ​including​ ​cold,​ ​wet​ ​and/or​ ​windy​ ​weather​ ​conditions, hot​ ​showers,​ ​baths,​ ​saunas,​ ​hot​ ​tubs,​ ​for​ ​24​ ​hours​ ​after​ ​treatment.

>I understand that all treatments at this facility are therapeutic in nature. I agree to communicate to the therapist any physical discomfort or draping issues during the session.

>If I choose to experience cupping therapy during treatments, I understand the potential side-effects and the after-care recommendations.

>I also agree that I have read, understand and will follow all the information stated above and will not hold the practitioner or Anjou Spa responsible.

I Agree

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First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's Information

Please list any known allergies.

Please list any existing medical conditions and any medications you are currently taking.
Are you under a doctor's care?*
No
Yes

If yes, please list name and facility.
Are you cleared from your doctor for massage?*
Yes
No
Recent operations, major illness, injuries or accidents that could help your massage therapist customize your treatment?*
No
Yes

If yes, please explain and list any dates.
Do you wear a pacemaker or have metal pins or metal implants?*
No
Yes
Do you have shingles currently or recently?*
No
Yes
Do you have warts and/or fungus currently?*
No
Yes
Are you currently on any blood-clotting or blood-thinning medications?*
No
Yes
Do you have a tendency to bruise easily?*
No
Yes

Are there any areas on your body you would like to be avoided? If yes, please explain.
How is your general stress level? (1 is low, 10 is intense)*
1
2
3
4
5
6
7
8
9
10

Where are you holding pain or tension in your body?

What goals do you hope to achieve through massage?
What level of pressure do you prefer? (choose one)*
light
medium
intense

Favorite areas to have worked on?

Favorite essential oils?
Have you recently had a miscarriage?*
No
Yes
Are you pregnant? If yes, please answer following questions. If no, please continue to the next screen.*
No
Yes

How many weeks pregnant are you?

Have you had a pregnancy treatment before?

What are your main areas of concern?

How does your skin and body feel?

What is your current body care routine?

Are you currently using any products to specially treat stretch marks?

Are you nursing?

What results would you like from your pregnancy massage today?
First Client's Signature*
Parent or Guardian's Email Address

Email
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A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Please tell us....

How did you hear about us?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Please list any known allergies.

Please list any existing medical conditions and any medications you are currently taking.
Are you under a doctor's care?*
No
Yes

If yes, please list name and facility.
Are you cleared from your doctor for massage?*
Yes
No
Recent operations, major illness, injuries or accidents that could help your massage therapist customize your treatment?*
No
Yes

If yes, please explain and list any dates.
Do you wear a pacemaker or have metal pins or metal implants?*
No
Yes
Do you have shingles currently or recently?*
No
Yes
Do you have warts and/or fungus currently?*
No
Yes
Are you currently on any blood-clotting or blood-thinning medications?*
No
Yes
Do you have a tendency to bruise easily?*
No
Yes

Are there any areas on your body you would like to be avoided? If yes, please explain.
How is your general stress level? (1 is low, 10 is intense)*
1
2
3
4
5
6
7
8
9
10

Where are you holding pain or tension in your body?

What goals do you hope to achieve through massage?
What level of pressure do you prefer? (choose one)*
light
medium
intense

Favorite areas to have worked on?

Favorite essential oils?
Have you recently had a miscarriage?*
No
Yes
Are you pregnant? If yes, please answer following questions. If no, please continue to the next screen.*
No
Yes

How many weeks pregnant are you?

Have you had a pregnancy treatment before?

What are your main areas of concern?

How does your skin and body feel?

What is your current body care routine?

Are you currently using any products to specially treat stretch marks?

Are you nursing?

What results would you like from your pregnancy massage today?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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