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Cupping Consent and Release Form

Cupping therapy involves applying suction cups to the skin to stimulate blood flow and relieve muscle tension. It has benefits for overall wellness but also risks if certain medical conditions are present like bleeding disorders, infections, or injuries. This document outlines the cupping process and asks the client to acknowledge they understand its risks, agree to communicate any discomfort, and release the practitioner from liability for unintended results.

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Zita Varga
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148 views

Cupping Consent and Release Form

Cupping therapy involves applying suction cups to the skin to stimulate blood flow and relieve muscle tension. It has benefits for overall wellness but also risks if certain medical conditions are present like bleeding disorders, infections, or injuries. This document outlines the cupping process and asks the client to acknowledge they understand its risks, agree to communicate any discomfort, and release the practitioner from liability for unintended results.

Uploaded by

Zita Varga
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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 Injured areas Skin lesions Phlebitis / varicose veins


Bleeding disorders Infections Cancer Impaired sensation
Bruise easily Acute skin conditions Areas of herniation Edema / lymphedema
Hemophilia Sunburn / rash Hematomas Certain medications

Please Read and Initial Each Item Below

________ 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 have been given an opportunity to ask questions about cupping therapy and have had my questions answered to
my satisfaction.

________ 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.

___________________________________________________ ___________/___________/___________
Client Name (Please Print) Date

___________________________________________________
Client Signature

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