Cupping Therapy - Consent and Release Form

ABOUT CUPPING THERAPY

Cupping is a therapeutic technique that comes from traditional Chinese medicine (TCM) and is believed to have numerous health benefits in addition to stimulating the flow of qi ("life force") within the body. This body treatment integrates well with massage therapy, and involves applying a localized negative pressure (suction) to the skin using glass, plastic or silicone cups at targeted areas of the body. The intent of this therapy is to stimulate the function of the circulatory and lymphatic systems. It may also help to release congested tissues and loosen adhesions at superficial tissues of the body.

Contraindications for Cupping Therapy

The following is a partial list of common conditions which are considered contraindications for cupping therapy:

Blood clots, Bleeding disorders, Bruise easily, Hemophilia, Skin lesions, Cancer, Areas of herniation, Hematomas, Phlebitis / varicose veins, Impaired sensation, Edema / lymphedema, Certain medications, Injured areas, Infections Acute skin conditions, Sunburn / rash

First name

Last name

Date

Information about massage cupping in general, techniques, potential benefits, effects, risks, after-care recommendations, and possible alternative therapies have been explained to me and I understand this information.

I understand that the vacuum formed by cupping may result in marks being left on my body.

My therapist has informed me of the contraindications of cupping therapy, and I have provided my therapist with an accurate and complete medical history to rule out any contraindications to receiving this treatment.

I agree to communicate to my therapist any physical discomfort experienced during the session.

I am not taking blood thinners, and I have no contraindications for cupping therapy.

I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment.

I further understand that massage and cupping therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the treatment should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.

By signing this form I agree with the statements above and give my consent to proceed with cupping therapy.

Signature

Massage Therapy Minor Consent Form

*Clients under the age of 18 must have this form completed by their parent or guardian.

-Massage service offered at this practice is for the purpose of general wellness, stress reduction, and relief of muscular tension.

-I (parent or guardian) must remain at this massage office for the duration of the minor's massage session. I may remain in the treatment room throughout the treatment. I (parent or guardian), the client, or the massage therapist may terminate the session at any time.

-The client does not have any injuries or conditions that prevent receiving massage therapy. I understand the importance of informing the massage therapist of all medical conditions and medications that the client is taking, and that there may be additional risks based on the client's physical or mental conditions.

-The client must immediately inform the therapist of any pain or discomfort so that the pressure or techniques used can be adjusted to remain within comfort limits. The massage therapist is not responsible for any pain or discomfort experienced during or after the treatment.

-I have been given the opportunity to ask questions about massage therapy and my questions have been answered. Also, I have been advised of the policies and procedures pertaining to massage and I understand these policies.

Information regarding massage in general, benefits, risks, contraindications of massage, and possible alternative therapies have been explained to me. I further understand that massage therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the massage should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.

Name of Client/Minor (Print)

Parent/Guardian Name (Print)

Age of Minor

Date

Signature

Couples' Massage Workshop Participant Agreement and Conduct Waiver

First name

Last name

Phone

Address

Date

I understand that the Couples’ Massage Workshop is intended to be a fun and interactive learning experience that will help improve communication between my partner and I, in addition to preparing us to give and receive the most effective and comfortable massages at home.

I understand the importance of being respectful in the workshop environment, as it can involve both intimate and vulnerable moments between partners.

I also understand that any comments, gestures, behaviors or attire that is/are deemed inappropriate are grounds for ending the workshop early for respective couples.

I understand that any disrespect aimed at the instructor, a partner, or other participant will not be tolerated and is cause for early dismissal from the workshop.

I understand that the massage techniques taught in this class are for home-use and recreational purposes only and should not take the place of medical treatment.

I understand and agree that videos and pictures taken at the workshops may be used for marketing and advertising purposes on my website and social media.

Signature