Cupping Therapy Massage Consent Form - Body Cupping

Cupping Therapy Massage Consent Form - Body Cupping

Name __________________________Email____________________

Address ________________________________________________

Contact Phone: ______________Birthday ___/___/___ 

Occupation _____________________ Referred By _________________ 

I ________________________agree to Cupping Massage Therapy performed on my body and/or face. By signing this agreement, I consent to gliding and parking cup techniques.

____ I understand that some risks of this procedure may include skin discoloration markings. The marks will resolve, and normal color will return to the skin from 1 to 14 days. Note, how quickly the marks resolve is dependent on the deepness of color of the marks, the hydration and circulation of the client. 

Cupping Massage Therapy may cause some clients to feel a little depleted after the session which is normal since the body is releasing toxins and chronic stagnation. Recommendation: rest and allow the body to release the toxins and restore balance; stay hydrated.

 ____ I do not have any known allergies, including latex, vinyl, silicone, or lubricants

____ I do not have any skin conditions including active acne, rashes, warts, or eczema

____ I do not have any blood disorders

____ I do not have bulging or herniated discs or sciatica

____ I do not have Cancer; including skin cancer

____ I do not have any cardiac conditions; including uncontrolled high blood pressure

____ I am not currently taking blood thinners

____ I do not have Diabetes

____ I am not pregnant at this time

____ I do not have lymphatic condition; swollen glands, nasal congestion, or edema

____ I do not have varicose veins or blood blots 

____ I have not had recent surgery, injury or accident-whiplash, sprain, or bruising

____ I do not have weak, ulcerated or broken skin

____ I do not have numbness or tingling

____ I do not have Tendonitis or Bursitis

____ I do not have Liver or Kidney diseases

____ I do not have Hepatitis

____ I do not have joint problems or stiffness, -arthritis, 

____ I do not have Osteoporosis

 On a scale from 1-10, 10=highest, rate levels of: Stress ___ Pain ___ Energy ___ 

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. 

My therapist has informed me of the likelihood of a skin discoloration mark forming and I understand that it is not harmful and will clear in a few days.

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. 

I affirm that I have notified my therapist of all known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. 

I understand that massage is entirely therapeutic and non-sexual in nature. 

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. 

Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or band. This is your massage and you should be as comfortable as possible. Feel free to ask your therapist any questions before, during, or after the session. 

____This agreement will remain in effect for this service and all future. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to treatment. I release the technician or business (______________________) from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. Our business is not responsible for any technician errors. By signing below, I verify that I have read and understand the above statements and agree to them.

Permission is granted to take before and after photos which may be used for marketing purposes.

 Client Signature: _________________________Date:___/___/____

 Wellness Provider Signature: ___________________Date___/___/____