Fire Cupping is NOT recommended if you are experiencing any of the following:
-Are/have recently been fasting or have an empty stomach
-Have a burn or sunburn in the area to be cupped.
-Recent trauma, inflamed or infected tissue, bleeding or fracture
-Within 24 hours of a sports injury
-Grade 3 ligament or sprain or tendon rupture
-Prone to bleeding or Hemophilia, purpura hemorrhagic, Leukemia, capillary fragility test positive
-Damaged site of dermatologic disease in the area to be worked, contagious skin disease or serious skin allergies
-Have been diagnosed with Malignant tumors.
-Severe edema, moderate or severe heart disease, heart failure, cirrhosis, ascites of the liver or an active tuberculosis sufferer
-Less than 6 months of pregnancy
-Varicose veins in the area
-Under the influence of drugs and/or alcohol

People who are on blood thinners should not experience Fire Cupping Massage. If you start taking such medication please inform the therapist so your treatment plan can be adjusted.

*I am on blood thinners (Treatment is not recommended)
*I am on blood thinners, but my condition is under control and my Dr has approved Fire Cupping Massage

Please check the boxes below as you read through each statement:
-I understand there are no guarantees regarding its use and effects and that I am free to stop the cupping treatment at any time.
-I understand that cupping commonly leaves marks on the skin that vary in pattern and colour (from light to dark purple) and usually last 3 days to a week, and sometimes longer
-I understand that Fire Cupping should not be combined with aggressive exfoliation, done within 4 hours of shaving, after a 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 24 hours. Exposure to such extremes can produce undesirable effects and I should avoid such situations.
-I understand that I should avoid caffeine, alcohol, sugary foods and drinks, dairy and processed meats and I should consume an abundance of clean water
-Although uncommon, I understand there are unexpected/rare risks such as bleeding, blisters or burns

Accuracy of Information:
I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

Client Release:
-I understand and acknowledge that fire cupping is performed by suction through negative pressure by inserting fire into the cup to draw out the oxygen at certain points on the body in attempt to treat bodily dysfunction, to modify or prevent pain perception, and to normalize the body’s physiological functions.
-I am aware and acknowledge that although extremely rare, certain adverse effects may result. Including but not limited to: local bruising, blisters, burns, bleeding, pain or discomfort or possible aggravation of symptoms existing prior to cupping treatment.