Lavande Difference
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Therapist
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Contact Us
Lavande Difference
Services
Therapist
Policies
Forms
Contact Us
Soft Cupping Consent
Soft Cupping: Massage Consent Form
Name
*
First Name
Last Name
Phone
*
Email Address
*
Do you currently have any of the following medical conditions: Cardiovascular disease, Renal disease/insufficiency, Hepatic Cirrhosis, Severe edema, Seizures, Epilepsy, or any Hemorrhagic diseases
*
Soft cupping in contraindicated for the above medical conditions
No
Yes
Women: are you currently pregnant?
Soft Cupping is contraindicated during pregnancy
Select one
No
Do you have varicose or spider veins?
*
Select one
No
Yes
Do you have a herinated disc/bulging disc
*
Select one
No
Yes
Are currently on any blood thinning medications?
*
A doctor's written approval is necessary for clients on blood thinners
Select one
No
Yes
Soft cups utilize a negative pressure which creates a vacuum to underlying skin. Erythema, slight reddening of the skin, and slight bruising may occur but should dissipate with in a few days. I acknowledge that it is my responsibility to inform the therapist if the pressure exerted by the cup is too strong. I understand that some degree of skin marking or bruising is possible.
*
Initial below to consent to soft cupping therapy
Thank you!
Health History
Utah Massage Waiver
Lava Shell Consent
Soft Cupping Consent
Prenatal Massage Form
Kinesio-tape Consent
