Hijama Cupping Therapy Consent Form

A copy of this completed consent form along with post treatment advice will be emailed to the email address you provide below.

    Optional Fertility Questions
    • The practitioner has fully explained the Hijama Cupping Therapy procedure, contraindications, outcomes, after effects and post care instructions of the procedure to me and I understand the process of Hijama Cupping Therapy.
    • I understand it is my responsibility to inform the practitioner of any changes in my medical condition or medications and agree to do so at the start of the Cupping sessions.
    • I give permission to the practitioner to safely and professionally perform Cupping Therapy be it Dry Cupping, Moving Cupping / Massage Cupping or Wet Cupping (Hijama) on my entire body (if required) including head and face (if required), to create incisions by breaking the skin barrier with a size 15 single use, sterile blade within the circle of the Cupping site. Also to clean and sanitize the treated area.
    • I have discussed the Cupping treatment with my Doctor / GP / Surgeon (if required) and been given the go ahead to perform Cupping Therapy.
    • I understand that the practitioner cannot be held responsible or liable for any contraindications, negative after effects, side effects, injuries, accidents or other liabilities after or during the cupping therapy session including Dry Cupping, Moving Cupping / Massage Cupping and Wet Cupping (Hijama).