Cupping Therapy Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Do you have any medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Have you tried Cupping Therapy previously? *

What are your reasons for having Cupping Therapy? *

What are your goals and expectations from Cupping Therapy? *

Treatment Information

Cupping therapy is an ancient form of alternative medicine in which a therapist puts special cups on your skin for a few minutes to create suction. People get it for many purposes, including to help with pain, inflammation, blood flow, relaxation and well-being, and as a type of deep-tissue massage.

The cups may be made of:

Glass
Bamboo
Earthenware
Silicone

Cupping therapy might be trendy now, but it’s not new. It dates back to ancient Egyptian, Chinese, and Middle Eastern cultures.

There are different methods of cupping, including:

Dry: Your provider heats the inside of each cup — typically with an alcohol-soaked cotton ball that is set aflame. The heat sends oxygen out of the cup, creating a vacuum. Some providers use a suction device to remove air from cups. Once placed on your skin, the vacuum force pulls skin up into the cup.
Wet: Your provider uses a needle to lightly puncture your skin before, and sometimes after, cupping. Toxins leave the body through the puncture wounds during the cupping procedure.

During both types of cupping, your therapist will put a flammable substance such as alcohol, herbs, or paper in a cup and set it on fire. As the fire goes out, they will put the cup upside down on your skin. As the air inside the cup cools, it creates a vacuum. This causes your skin to rise and redden as your blood vessels expand. The cup is generally left in place for up to 3 minutes.

A more modern version of cupping uses a rubber pump instead of fire to create the vacuum inside the cup. Sometimes therapists use silicone cups, which they can move from place to place on your skin for a massage-like effect.

Wet cupping creates a mild suction by leaving a cup in place for about 3 minutes. The therapist then removes the cup and uses a small scalpel to make light, tiny cuts on your skin. Next, they do a second suction to draw out a small quantity of blood.

You might get 3-5 cups in your first session. Or you might just try one to see how it goes.

Afterward, you will get an antibiotic ointment and bandage to prevent infection. Your skin should look normal again within 10 days.

Cupping therapy can be used to treat:

Blood disorders such as anemia and hemophilia
Rheumatic diseases such as arthritis and fibromyalgia
Fertility and gynecological disorders
Skin problems such as eczema and acne
High blood pressure
Migraines
Anxiety and depression
Bronchial congestion caused by allergies and asthma
Varicose veins

Possible side effects

Cupping is a relatively low-risk therapy. Still, you may experience:

Burns from heated cups
Fatigue
Headaches
Muscle tension or soreness
Nausea
Skin infections, itching or scarring

Aftercare Advice

Cupping is a traditional treatment that is safe, comfortable, and effective for many health disorders. The gentle suction that cupping creates loosens and lifts connective tissues, which increases blood and lymph flow to your skin and muscles. To get the maximum benefits from cupping, it’s important that you follow a few guidelines.

What to do after cupping or a cupping massage:

Drink a lot of water - Water helps flush your lymphatic system of the cellular waste that cupping helps release from your tissues.
Stay warm - Try to cover the area(s) where you received cupping.
Rest - You may feel more tired than normal or experience flu-like symptoms after cupping (headache or general body aches). This is a temporary reaction by your immune system to the cellular waste that cupping helps release.

What to avoid after cupping or a cupping massage:

For 4-6 hours post cupping, avoid exposure to:

Caffeine, alcohol, sugary foods and drinks, dairy, and processed meats - These foods slow down your body’s ability to process the treatment.
Hot showers, saunas, hot tubs and strong air conditioning - After cupping, your skin will be more sensitive to temperature in the areas where the cups were placed. Give your skin time to recover. If possible, shower with filtered water to avoid reintroducing unnecessary chemicals onto your skin.
Intense exercise
Cold and windy conditions

How to make the cupping marks go away faster:

After cupping, your skin will have circular marks ranging in color from pink to deep red or purple. People may joke that you look like you were in a fight with an octopus. Wear those badges proudly! You’re doing something great for your body.

Discolorations from cupping will fade. Some may fade after a few hours while others take up to two weeks to disappear completely. The discolorations are related to your body’s health at the time of cupping.

If you’d like those marks to go away faster, do two things: hydrate and rest.

Everyone’s body responds differently to cupping. If you have any questions either before or after a cupping appointment, please call us.

Please tick the box to confirm: *

I have read and understood the aftercare advice.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive Cupping Therapy.

Client Signature: *

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