Cupping Intake Form
Please complete the intake questions and review the consent statement.
Do you currently have (or have you had in the past) any of the following conditions?
*
Heart problems
Heart attack
Stroke
Liver disease
Kidney disease
None
Are you currently taking blood thinners?
*
Yes
No
Are you currently pregnant?
*
Yes
No
Are you currently undergoing cancer treatments or radiation?
*
Yes
No
I understand the risks of bruising & muscle soreness that may occur directly or indirectly from cupping treatments. I release the massage therapist/practitioner and business of any and all liability from harm that may unintentionally occur during my treatment(s).
*
I agree
Signature
*
Printed name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: