Cupping Therapy Client Release Form
• I understand that all treatments at this office are therapeutic in nature. I agree to communicate
to the therapist any physical discomfort or draping issues during the session.
• Information has been provided to me about the Cupping Therapy. If I choose to experience
these therapies during treatments, I understand the potential effects and after-care
recommendations.
• It has been explained to me that there are contraindications for Cupping Therapy. I have fully
disclosed all health factors to my therapist, including those not mentioned on my intake form, to
avoid any complications.
• I am not taking blood thinners, experiencing a fever, cancer, had recent surgery, have
hemophilia or bleeding / clotting disorders, diabetes, abnormal blood pressure, nor am I
currently pregnant.
• It has also been explained to me that there is the possibility of discolorations or bruise like
markings that can occur from breaking up myofascial congestion or stagnation in my body.
• I further understand that the discolorations or bruise like markings are contusions (bruises) and
will dissipate from a few hours to as long as 2 weeks in some cases in relation to my after-care
activities.
• I understand that the first time I experience Cupping, my body’s immune system can
temporarily react to this release as it might with the flu- producing effects like nausea,
headache, and aches that will subside in time with rest and water. Water helps to dilute the
intensity of the release.
• I understand that the Cupping therapy modalities should not be combined with aggressive
exfoliation, 4 hours after shaving, after sunburn, or when I’m hungry or thirsty.
• I understand that I should avoid exposure to cold, wet, and/or windy weather conditions, hot
showers, baths, saunas, hot tubs, and aggressive exercise for 4-6 hours. I understand that
exposure to such extremes can produce undesirable effects.
• I agree to disclose to A Step Beyond Massage Therapy if my medical health history would
happen to change during the time period of receiving Cupping Therapy.
• I have read all of the above disclaimer and I agree that I am not currently experiencing any of
the contraindications. I have had to opportunity to ask any questions about this treatment, and
by signing below I agree to release A Step Beyond Massage Therapy and its therapists from any
liability in connections with receiving Cupping treatments.
Client Name _________________________________________________(please print)
Signature ___________________________________________ Date________________
