Emily Chapman, LMT MMP | Cupping Form

Please fill out the following consent form prior to your first massage appointment with Emily. We look forward to seeing you soon!

Contraindictions for Cupping Therapy | The following is a partial list of common conditions which are considered contradictions for cupping therapy:

• Blood Clots
• Bleeding disorders
• Bruise easily
• Hemophilia
• Injured areas
• Infections
• Acute skin conditions
• Sunburn / Rash
• Skin lesions
• Cancer
• Areas of herniation
• Hematomas
• Phlebitis / Varicose veins
• Impaired sensation
• Edema / Lymphedema
• Certain medications

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. *

Client Initials

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

Client Initials

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. *

Client Initials

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

Client Initials

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

Client Initials

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

Client Initials

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

Client Initials

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. *

Client Name (First, Last)

Signature *

Client Signature

Date *

MM/DD/YY

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