Cupping Therapy Consent Form
I understand that all treatments at this facility are therapeutic in nature. I agree to communicate to the therapist any physical discomfort during the session.
I agree to follow aftercare recommendations that will be offered to me after the treatment.
I understand that there is the possibility of discolorations that can occur from the release and clearing of stagnation and toxins from my body
I also understand that this reaction is not bruising, but due to stagnant blood and cellular debris, and toxins being drawn to the surface to be clear away by my circulatory system.
Though a rare occurrence, toxic release can show up in the form of tiny bubbles after cupping. Be sure to keep these areas clean and sanitized until fully healed.
I further understand that the discolorations will dissipate from a few hours to as long as 2 weeks in some cases and in relation to my aftercare activities.
I understand that, though it is rare, my body’s immune system might temporarily react to the toxic release as it would with the flu producing flu-like effects. Hydration and having a meal helps to dilute the intensity of the release.
I attest that I do not have any of the following conditions which would be contraindicated for cupping therapy: pregnancy, skin rash, open wounds, or infections, hemophiliac disease, burns, actively taking coumadin or other blood thinners.
Acne, abrasions, and cuts must be reported to the practitioner before the cupping session to avoid bleeding from the cupping.
I understand that Cupping Therapy modalities should not be combined with aggressive exfoliation, 4 hrs after shaving, after sunburn or when I’m excessively hungry or thirsty.
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.
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