Cupping Release Form

Please fill out the form below at least 24 hours before your appointment.

Cupping Release Form

Cupping Contraindications

Cupping therapy is not suitable for everyone. There are risks associated with performing cupping therapies on individuals with the following conditions.

You must inform your massage therapist/practitioner if you have any of the following conditions which may make cupping contraindicated or may require your therapist/practitioner alter the treatment.

Bruises
Pregnancy
Diabetes
Inflammatory skin conditions
Open wounds, sores, or thinning skin
Hypotension or Hypertension
Cancer (with or without treatment)
Varicose veins
Under the influence of drugs or alcohol
Blood clot(s)
Cardiovascular disease
Neuropathy
Autoimmune condition (MS, Lupus, RA, etc.)
Peripheral vascular disease
Heat sensitivity
Edema or Lymphedema
Blood thinning medications

Client's Release

I have read and understood the aforementioned conditions that make cupping contraindicated. The massage therapist/practitioner has discussed this information with me and provided the opportunity to ask questions. I have disclosed any and all risk factors.

Please check the following that applies to you.

I understand the information contained on this form and confirm that I do not have any of the above conditions.

My condition(s) of ________________________________ is/are listed and therefore make(s) cupping contraindicated. Given this knowledge I hereby give my full consent to receive cupping therapy and take full responsibility of any side effects or harm that may come from receiving cupping therapy.

I understand that I will be receiving cupping as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I understand the risks of bruising and muscle soreness that may occur directly or indirectly from cupping treatment. I release the massage therapist/practitioner and business of any and all liability for any harm that may unintentionally occur during my treatment(s).

Signature

Date