Massage Intake Form

Please check any symptoms that apply:

Precautions and Contraindications
Cupping therapy, in general, is very safe and has no lasting side effects. There are a few exceptions, however, and when these are observed the implementation is safe and the benefits are generous. Precaution is necessary when treating clients who may be on anticoagulant drugs, or have an empty stomach, particularly during long fasting periods such as the holy Ramadan month, as fasting temporarily weakens the body’s energy.
Cupping should not and will not be employed over:

Eyes
Sunburns
Burns in general
Open wounds
Recent trauma
Varicose veins
Pregnancy
Disorders affecting the internal organs

Aftercare Tips
Drink plenty of water after your treatment
Eat a small, easily digestible meal within two hours of your treatment
Get plenty of rest the night of your treatment
Avoid drafts and chills
Apply arnica gel or gentle healing balm if any tender areas

I understand that all treatments are therapeutic in nature. I agree to notify the therapist of any physical discomfort or draping issues during sessions. I voluntarily to receive cupping therapy treatments and release the therapist and the facility from any liability for any injury or harm that may result from this treatment.

MyoHarmony has provided me with information on Massage/Medicupping therapy. If I choose to experience this therapy in my treatment, I understand the effects and after-care recommendations. It has been explained to me that there is the possibility of a skin discoloration, or “cup kiss,” appearing as tissue is released. I am aware that a “cup kiss“ is not bruise and that it Will dissipate within a few hours to a few days.

MyoHarmony will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during a session. I have stated all relevant physical conditions and will inform the therapist of any changes in my health.

Instrument-assisted soft tissue mobilization (IASTM) is a technique that uses specially designed instruments to manipulate the skin, myofascia, muscles, and tendons by various direct compressive stroke techniques. It is used to assess tissue quality and treat areas identified to have scar tissue, soft tissue restrictions, chronic inflammation or degeneration. Common diagnoses treated with IASTM include plantar fasciitis, tendinitis, carpal tunnel, and IT Band syndrome. IASTM works like a standard massage, but specialized instruments are used in place of a therapist's hands, allowing for more direct treatment of the soft tissues involved with movement.

Possible side effects from IASTM should be minor if any. It is normal to have some mild tenderness or redness around the affected area, but this should clear up within hours or a couple of days afterward. It isn’t abnormal to also have some minor bruising around the area, although this isn’t necessary to obtain the desired effect.

I understand that all treatments are therapeutic in nature. I agree to notify the therapist of any physical discomfort or draping issues during sessions. I voluntarily choose to receive cupping therapy treatments and release the therapists and the facility from any liability for any injury or harm that may result from this treatment.

MyoHarmony has provided me with information on IASTM therapy. If I choose to experience this therapy in my treatment, I understand the effects and after-care recommendations. It has been explained to me that there is the possibility of a skin discoloration, appearing as tissue is released. I am aware that the discoloration is not bruise and that it will dissipate within a few hours to a few days.

MyoHarmony will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during a session. I have stated all relevant physical conditions and will inform the therapist of any changes in my health.

Client information are confidential and written authorization is required to release any information.

We do not double book appointments

Please reschedule session if more than 15 minutes late

24 hour cancellation notice is required 

You will be draped and at no time be exposed

You will have a consultation with your therapist to discuss the session

You my end the session at any time for any reason

Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.

I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist. 

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

By my electronic signature below, I agree to the massage policy and client agreement above.