I understand that all treatments at this facility are therapeutic in nature. I agree to communicate to the therapist any physical discomfort or draping issues during the session. Information has been provided to me about Cupping Therapy. If I choose to experiences these therapies during treatments, I understand the potential effects and after-care recommendations. It has been explained to me that there are contraindications for Cupping Therapy. I have fully disclosed all health factors to my therapist, including those not mentioned on my Intake Form, to avoid any complications. It has been explained to me that there is the possibility of discolorations that can occur from the release and clearing of stagnation and toxins from my body. I also understand that this reaction is not bruising, but do to cellular debris, pathogenic factors and toxins being drawn to the surface to be cleared away by the circulatory system. I further understand that the discolorations will dissipate from a few hours to as long as 2 weeks in some cases and in relation to my after-care activities I understand that Cupping Therapy modalities should not be combined with aggressive exfoliation, 4 hours after shaving, after sunburn or when I'm hungry or thirsty. I understand that if I am sick and/or congested, receiving cupping may result in blistering from the result of the toxins being released. I understand that I should avoid exposure to extreme cold, wet and/or windy weather conditions, hot showers, baths, saunas, hot tubs and aggressive exercise for 24 hours. It has been explained to me that exposure to such extremes can product undesirable effects and I should avoid such situations.

Iunderstand that I should avoid caffeine, alcohol, sugary food and drinks, dairy and processed meats and I should consume an abundance of water.

(print name) agree to allow Healing Elements to perform Cupping. I also agree that I have read, understand and will follow all of the information stated above and will not hold the practitioner responsible.