Cupping Therapy Informed Consent
Cupping therapy is an ancient form of alternative medicine used to assist with pain management, inflammation, blood flow, relaxation and well-being, and as a type deep tissue massage. However, 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 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.
Inflammatory skin conditions
Open wounds, sores, or thinning skin
Hypotension or Hypertension
Under the influence of drugs or alcohol
Autoimmune condition (MS, Lupus, RA, etc.)
Peripheral vascular disease
Compromised immune system
Edema or Lymphedema
Blood thinning medications
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.
Information has been provided to me about cupping therapy. If I choose to experience these therapies during treatment, I understand the potential effects and after-care recommendations
It has been explained to me that there are contraindications for cupping therapies. I have fully disclosed all health factors to my therapist, including those not mentioned on my intake form, to avoid any complications.
I understand that this reaction is not bruising, but due to cellular debris, pathogenic factors and toxins being drawn to the surface to be clear away by my circulatory systems. I understand that there is a possibility of discolorations that can occur from the release and clearing of stagnation and toxins from my body.
I understand that the first time I experience cupping therapy, my body’s immune system can temporarily react to this release as it might with the flu—producing flu-like effects like nausea, headaches, and aches that will subside in time with rest and water. Water helps to dilute the intensity of the release.
I understand that cupping therapy modalities should not be combined with aggressive exfoliation, 4 hrs after shaving, after sunburn or when hungry or thirsty.
I understand that I should avoid exposure to cold, wet and/or windy conditions, hot showers, baths, saunas, hot tubs and aggressive exercise for 4-6 hours. I understand that exposure to such extremes can produce undesirable effects and I should avoid such situations.
I understand that I should avoid caffeine, alcohol, sugary foods and drinks, dairy and processed meats and I should consume an abundance of clean water.
I Agree I agree to allow the cupping practitioner to perform cupping. I also agree that I have read, understand and will follow all of the information stated above and will not hold the practitioner responsible.
September 16, 2021