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Cupping Release Form

 

Cupping Contraindications

Cupping therapy is not suitable for everyone. There are risks associated with performing cupping therapies on individuals with the following conditions.

You must inform your massage therapist/practitioner if you have any of the following conditions which may make cupping contraindicated or may require your therapist/practitioner to alter the treatment.

  • Bruises
  • Pregnancy
  • Blood clot(s)
  • Cardiovascular disease
  • Diabetes
  • Neuropathy
  • Inflammatory skin conditions
  • Autoimmune condition (MS, Lupus, RA, etc.)
  • Open wounds, sores, or thinning skin
  • Peripheral vascular disease
  • Hypotension or Hypertension
  • Heat sensitivity
  • Cancer (with or without treatment)
  • Compromised immune system
  • Varicose veins
  • Edema or Lymphedema
  • Under the influence of drugs or alcohol
  • Blood thinning medications

Cupping Therapy is considered safe. However, risk of bruising and muscle soreness may occur directly or indirectly from Cupping Therapy. 

Client's Release

I have read and understand the aforementioned conditions which make cupping therapies contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed any and all health risk factors.

Today's Date: November 21, 2024

First Client's Name

First Name*

Last Name*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Please check the following that applies to you.
I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of

is/are listed above and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from my receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

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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