Xcelerate Rehab Sports Therapy

Xcelerate Rehab Sports Therapy
FEMALE CLIENTS ONLY • MOBILE SERVICE
Client Intake & Consent Form
Dry/Wet Cupping (Hijama)
(Confidential Health Information - For Professional Use Only)
Client Information
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
Occupation:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postcode:
Contact Number:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact Name:
Emergency Contact Number:
Format: (000) 000-0000.
Relationship:
GP Surgery Contact Name:
GP Surgery Contact Number:
Format: (000) 000-0000.
Type of Treatment Requested
Type of Treatment Requested
Medical History
Please tick (✓) if you currently have or have had any of the following conditions:

Medical History

Rows	Yes	No	Notes
High or Low Blood Pressure
Diabetes
Epilepsy / Fainting Spells
Pregnancy
Skin Conditions (Eczema, Psoriasis, Acne)
Varicose Veins
Liver / Kidney Disease
Blood Clots / DVT
Recent Surgery (within 6 months)
Infections / Fever
Cancer / Chemotherapy/Radiotherapy
Recent Blood Donation
Anaemia / Low Iron
Bleeding Disorders (e.g. Haemophilia)
Blood Thinners (Warfarin, Aspirin etc.)
Heart Diseases / Heart Attacks
Other

Contraindications & Safety Checklist

Rows	Yes	No
Have you eaten within the last 2-3 hours?
Are you currently menstruating?
Are you pregnant (or suspect pregnancy)?
Have you donated blood in the last 2 weeks?
Do you have any open wounds, cuts, or infections on the treatment area?
Do you feel weak, dizzy, or unwell today?
Have you had cupping or massage in the last 24 hours?

Precautions & Aftercare
Please note:
- Cupping should not be done over varicose veins, broken skin, or directly over arteries, joints, the spine, heart, breasts, or genitals.
- Avoid cupping if you are very weak, dehydrated, fasting, or immediately after exercise or a heavy meal.
- Mild redness or circular marks are normal and may last several days.
- Keep the area covered, warm, and dry after treatment.
- Avoid showering, heavy meals, or physical activity for at least 12-24 hours post-treatment.
Additional Information
Female Clients Only
Xcelerate Rehab Sports Therapy provides treatment to female clients only.
Mobile Service
All treatments are carried out in the comfort and privacy of your home.
Fully Insured
Xcelerate Rehab Sports Therapy is fully insured with £5 million Public Liability and Professional Indemnity cover.
Confidentiality
All personal and medical information is kept strictly confidential and will only be used for professional purposes.
Cancellation Policy
Please provide at least 24 hours' notice to cancel or rearrange appointments. Late cancellations may be subject to a fee.
Client Consent
By signing below, I confirm that:
- The information provided above is true and complete to the best of my knowledge.
- I have informed my practitioner of all relevant medical conditions.
- I understand the nature of Hijama/Cupping therapy, including potential mild side effects (e.g. redness, slight bruising, or light-headedness).
- I have had the opportunity to ask questions, and I consent to proceed with the treatment.
- I understand tat results cannot be guranteed and that individual resonses to treatment may vary.
Thank you for trusting
Xcelerate Rehab Sports Therapy
with your health and wellbeing.
If you have any questions before or after your treatment, please don't hesitate to contact me.
Client Signature:
Date:

MonthDayYear
Date
Should be Empty:

Xcelerate Rehab Sports Therapy

FEMALE CLIENTS ONLY • MOBILE SERVICE

Client Intake & Consent Form

Dry/Wet Cupping (Hijama)

Client Information

Type of Treatment Requested

Medical History

Precautions & Aftercare

Additional Information

Client Consent