Vacuu-Therapy

Patient Name*

Date of Birth*

Review and complete the sections below:

The Vacuum Cupping Treatment is a non-invasive treatment. It uses a vacuum applicator to draw in skin tissue. The procedure is for improving the appearance of cellulite, sculpting, contouring, & reducing or increasing circumferences depending on the application. It may also be therapeutic for improving circulation and muscle aches in the treated areas. It is not a weight-loss solution and it does not replace traditional methods such as liposuction.

It is the client’s responsibility to inform the technician of their comfort level so the pressure can be adjusted throughout the treatment. The suction pressure may cause sensations of deep pulling, tugging and pinching. You may experience tingling or aching as the treatment begins.*

Initial

I understand there is a possibility of short-term effects such as discomfort, reddening, temporary bruising and temporary discoloration of the skin.*

Initial

Bruising, swelling, and tenderness can occur in the treated area and it may appear red for a few hours after the treatment. *

Initial

Clinical results may vary depending on individual factors, including but not limited to the medical history, skin type, patient compliance with pre- and post-treatment instructions, and individual response to treatment. *

Initial

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the context of this consent form. *

Signature

The Vacuum Cupping involves a series of treatments and the fee structure has been fully explained to me. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. *

Initial

Do you have any of the following?

*Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy

*Impaired skin sensation

*Open or infected wounds

*Bleeding disorders or continuous use of blood thinners

*Recent surgery or scar tissue in the area to be treated

*A hernia or history of hernia in the area to be treated

*Skin conditions such as eczema, dermatitis, or rashes

If yes, please explain:

If non applicable type N/A

*Pregnancy or lactation

*Infection in the urinary system i.e. kidneys, bladder and urethra

*Crohn's Disease

If yes, please explain:

If non applicable type N/A

*Hyperthyroidism

*Deep Venous Thrombosis

*Lymphedema

*Impaired peripheral circulation in the area to be treated

If yes, please explain:

If non applicable type N/A

I confirm that I have informed my therapist regarding any current or past medical condition, disease or medication taken.*

Signature

POSSIBLE CONTRAINDICATIONS FURTHER DISCUSSION NEEDED

Diabetes - the body's inability or lowered ability to regulate blood sugar and fat levels can significantly hinder the proper removal of fat cell contents from the lymphatic system, thus lowering the overall effectiveness of the treatments

Thyroid problems - thyroid regulates overall metabolism of the body, thus it can deter the proper disposal of fat contents from the body, and hence also lower the overall effectiveness of the treatments Current or history of skin cancer or pre-malignant moles - In order to avoid and prevent any further irritation to these conditions' treatment of body areas with these conditions should not be performed. We recommend you talk with your physician before committing to any

Any active skin conditions - It is best to schedule treatment when any skin conditions in treatment areas such as sores, psoriasis, eczema, herpes and rashes are no longer active to avoid and prevent any further irritation of skin.

Alcohol and Caffeine - These substances will slow down lymphatic drainage of fatty acids and toxins. For best results, please try to avoid or reduce your intake of products that contain them during the course of treatment.

Infection in the urinary system i.e. kidneys, bladder and urethra Crohn's Disease Hyperthyroidism Deep Venous Thrombosis Lymphedema

If any of the above apply to you, please explain:*

If non applicable type N|A

SERVICE MUST BE POSTPONED IF ANY OF THE FOLLOWING APPLY TO YOU:

*Botox/Dysport within the past 2 weeks

*Cancer or post-cancer treatments

* Retin A within 5-7 days of treatment

*Sunburn

*Recent laser procedures or chemical peels within

*Blood Thinner Medication

*Viral Infection/influenza/cold sore

*Infection in the urinary system i.e. kidneys, bladder and urethra

*Crohn's Disease

*Hyperthyroidism

If any of the above apply to you, please explain:*

If non applicable type N|A

SERVICE MAY STILL BE PROVIDED BY THE DISCRETION OF JourneySkin Co. Staff:

I understand and acknowledge that cupping is performed by suction at certain points on the body in an attempt to treat buttocks enhancement, slimming, detox, anti-cellulite, pain management, and to stimulate lymphatic drainage. I am aware and acknowledge that certain adverse side effects may result.

I understand there are no guarantees regarding its use and effects and that I am free to stop the cupping treatment at any time.

I understand that vacuum cupping does commonly leave marks on the skin that vary in pattern and color (from light to dark purple) and could last a few hours or days.

I will inform Journey Skin Co. if my medical condition changes over the course of treatment.

By signing below, I certify that I have been given the opportunity to ask questions and that I have read and fully understand the context of this consent form.

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Vacuu-Therapy /Cupping