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Please read this fully. If there is any part that is uncelar, please ask for assistnace. DO NOT SIGN if there is any part that is unclear. By signing you signify that you understand fully. 

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.

 

Bruises
Pregnancy
Diabetes
Inflammatory skin conditions
Open wounds, sores, or thinning skin
Hypotension or Hypertension
Cancer
Varicose veins
Under the influence of drugs or alcohol
Blood clots
Cardiovascular disease
Nueropathy
Autoimmune condition (MS, Lupus, RA, etc.)
Peripheral vascular disease
Heat sensitivity
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.

 

 

 

         June 18, 2021

 

 

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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.
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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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