Cupping Contraindications
Cupping therapy is not suitable for everyone. There are risks associated with performing cupping therapies 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 to 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 clots) 
  • Cardiovascular disease 
  • Neuropathy 
  • Autoimmune condition (MS, Lupus, RA, etc.) 
  • Peripheral vascular disease 
  • Heat sensitivity
  • Compromised immune system 
  • Edema or Lymphedema 
  • Blood thinning medications Client's Release 
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Client's Release
Please check the following that applies to you.
I have read and understand the aforementioned conditions which make cupping therapies contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed any and all health risk factor. *
Required
I understand the information contained on this form and confirm that I do not have any of the above conditions.
 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 above 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 my 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). *
Required
Client's Full Name *
Date *
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A copy of your responses will be emailed to the address you provided.
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