Cupping | Hot Stones | Body Contour Release Form

Cupping Release Form

Please fill in if you are doing this service.
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
- Blood clot(s)
- Pregnancy
- Diabetes
- Cardiovascular disease
- Neuropathy
- Inflammatory skin conditions
- Open wounds, sores, or thinning skin
- Hypotension or Hypertension
- Cancer (with or without treatment)
- Varicose veins
- Under the influence of drugs or alcohol
- Autoimmune conditions (MS, Lupus, RA, etc)
- Peripheral vascular disease
- Heat sensitivity
- Compromised immune system
- Edema or Lymphedema
- Blood thinning medications
Client's Release
I blanks , 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.
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 aboveMy 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).
Signature

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Today's Date

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Hot Stones Massage Release Form

Please fill in if you are doing this service.
Hot Stone Massage Contraindications

Hot stone massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions.

You must inform your massage therapist/practitioner if you have any of the following conditions which may make hot stone massage contraindicated or may require your therapist/practitioner to alter the massage.
- Blood clot(s)
- Pregnancy
- Diabetes
- Neuropathy
- Autoimmune conditions (MS, Lupus, RA, etc)
- Inflammatory skin conditions
- Open wounds or sores
- Peripheral vascular disease
- Heat sensitivity
- Hypotension or Hypertension
- Cancer (with or without treatment)
- Compromised immune system
- Edema or Lymphedema
- Under the influence of drugs or alcohol
- Cardiovascular disease
I blanks,have read and understand the aforementioned conditions
which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided the opportunity for any questions. I have disclosed any and all health risk factors.
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) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.
I understand that I will be receiving hot stone massage as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during my treatment(s).
Signature

Clear
Today's Date

MonthDayYear
Date

	Yes	No
Cardiovascular Disease
Kidney Disease
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV
Liver Disease
Skin Disease
Thyroid Glad Problems
Gastrointestinal Problems

Cupping Release Form

Client's Release

Hot Stones Massage Release Form

Body Contouring Client Intake Form

Medical Condition