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Home
YOGA TEACHER TRAINING
EVENTS
Yoga Therapy
SERVICES
Cupping Therapy
Stretch Therapy
Yoga Classes
CLASS SCHEDULE
CLASS SIGN UP
Public Classes
Book
ABOUT
CONTACT
OM VIP
FREE CONSULT
BLOG
EAT
MOVE
LIVE
MEDIA
CUPPING THERAPY WAIVER
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Name
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First
Last
Date of Birth (mm-dd-yyyy)
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Email
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Phone Number
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Briefly describe ALL muscular tension/soreness, pain and/or injury you are currently experiencing and your goals with Cupping Therapy.
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Ø I understand that all treatments at this facility are therapeutic in nature. I agree to communicate to the therapist any physical discomfort or draping issues during the session.
Ø Information has been provided to me about Cupping Therapy. IF I choose to experience these therapies during treatments, I understand that potential effects and after-care recommendations. Ø It has been explained to me that there are contraindications for Cupping Therapy. I have fully disclosed all health factors to my therapists, including those not mentioned on my Health History Intake Form, to avoid any complications.
Ø It has been explained to me that there is the possibility of discolorations that can occur from the release and clearing of stagnation and toxins from my body.
Ø I also understand that this reaction is not bruising, but due to cellular debris, pathogenic factors and toxins being drawn to the surface to be cleared away by my circulatory systems.
Ø I further understand that the discolorations will dissipate from a few hours to as long as 2 weeks in some cases and in relation to my after-care activities.
Ø I understand that Cupping Therapy modalities should not be combined with aggressive exfoliation, 4 hours after shaving, after a sunburn or when I’m hungry or thirsty.
Ø 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. It has been explained to me that exposure to such extremes can produce undesirable effects and I should avoid such situations.
Ø 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.
**IMPORTANT
: By completing this form, you agree to receive information from Yoga Fits Me. You may opt out of receiving emails at any time.
Agreement Acknowlegement
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By clicking here, I agree to allow the Cupping Practitioner Jennifer Butler to perform Cupping Therapy. I also agree that I have read, understand and will follow all of the information stated above and will not hold the Jennifer Butler and/or Yoga Fits Me responsible.
Today's Date (mm-dd-yyyy)
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