Cupping Therapy Massage Consent Form - Facial Cupping

Cupping Therapy Massage Consent Form - Facial 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 skin condition; active acne, rash, warts, rosacea, weeping eczema

____ I do not have any blood disorders

____ 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 gland, nasal congestion, edema

____ I do not have varicose veins or blood blots 

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

____ I do not have weak, ulcerated or broken skin

____ I do not have Headaches or Migraines

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

____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___/___/____