Disclosure and Consent for Massage Cupping and Gua Sha

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. There is never any anticipation of adverse reactions from massage therapy but the following is to provide information for the patient about massage techniques and possible outcomes.

Massage therapy may include deep pressure, applied heat, stretching and percussion. Some possible reactions include the original pain not resolving, bruising, headaches or nausea.

Massage Cupping and Gua Sha are therapeutic decompression techniques used by massage therapists, acupuncturists and body-workers 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. Gua Sha is similar to cupping in results, but a round-edged tool is used in strokes to pressure specific areas of muscle pain.

It has been explained to me that there are contraindications for cupping and gua sha. I have fully disclosed all health factors to my therapist to avoid any complications.

CONTRAINDICATIONS include, but are not limited to:

SEVERE DISEASES - such as cardiac failure, renal failure, ascites due to hepato-cirrhosis and severe edema, as well as hemorrhagic
diseases such as allergic pupura, hemophilia and leukemia, and clients with
dermatosis, destruction of skin, or allergic dermatitis. Broken bones, dislocations,
slipped discs, those undergoing cancer treatments such as radiation (check with
doctor), sunburn, ruptured/ulcerated/inflamed skin,bleeding disorders, acute
stages of Psoriasis, Eczema, or Rosacea. Fever (YOU WILL BE SENT HOME) or dehydration - will not use cupping but massage is fine.

There is a possibility of discoloration that can occur from the release and clearing of stagnation and toxins being drawn to the subcutaneous layers for dissipation by the circulatory system.

The discoloration, or sha, 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.

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

o 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.

o I understand that when I experience cupping and/or gua sha, my body’s immune system can temporarily react to this release as it might with the flu, producing flu-like symptoms such as nausea, headache and soreness that will subside in time with rest and water. Water helps to
dilute the intensity of the release.
o I understand that cupping/gua sha modalities should not be combined with aggressive exfoliation, after getting a sunburn or when I’m hungry or thirsty.

o If I choose to experience cupping therapy and/or Gua Sha during treatments, I understand the potential side-effects and the after-care recommendations.

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