** Cupping (Hijama) Therapy Consent and Liability Waiver Form **
This form is designed to inform you about the potential risks and harms associated with cupping therapy during and after the procedure, and to state that you accept these risks. Signing this form means you agree not to hold the cupping studio liable for any adverse events that may occur during or after the therapy. Please read the following information carefully and sign the form to confirm that you understand and accept it.
** Consent and Acknowledgement **
Please read the following information carefully and check the boxes to indicate that you understand and accept each statement.
1. ** Historical and Islamic Context **
I understand that cupping has historical roots and is present in Islamic culture. It is used to expel toxins from the body and improve general health. This treatment method is chosen voluntarily.
2. ** Voluntary Acceptance **
I declare that I am participating in this therapy of my own free will and voluntarily accept it. This decision is made entirely of my own free will.
3. ** Infection Risk **
I acknowledge that the incisions made on the skin during cupping carry the risk of infection. Bacteria, viruses, and other pathogens can enter the skin, causing symptoms like redness, swelling, pain, and inflammation.
4. ** Skin Lesions and Injuries **
I understand that the incisions made on the skin can leave permanent scars or lesions. Improper incision depth can cause deep injuries, leading to longer healing times and more pain.
5. ** Bleeding and Hematoma **
I acknowledge that uncontrolled bleeding can cause symptoms such as dizziness, weakness, and fainting. Painful hematomas (bruises) can form due to blood accumulation under the skin, lasting for several weeks.
6. ** Allergic Reactions **
I understand that during cupping, olive oil, St. John's wort oil, and ozone oil are applied to the body. I declare that I am not allergic to these oils. Materials or antiseptics used can cause allergic reactions on the skin, manifesting as redness, itching, swelling, and rashes. Severe allergic reactions can lead to anaphylaxis, requiring emergency medical intervention.
7. ** Nerve and Vascular Damage **
I acknowledge that the incisions made on the skin during cupping can accidentally damage nerves or blood vessels, causing symptoms such as numbness or tingling in the affected area. Vascular damage can cause excessive bleeding, leading to serious medical problems.
8. ** Pain and Discomfort **
I understand that there may be pain and discomfort during and after the cupping procedure. The incisions and the vacuum effect of the cups can cause sensitivity and pain in the treated area, lasting for several days and affecting daily activities.
9. ** Bruising and Scarring **
I acknowledge that bruising and permanent scars may occur on the skin after the cupping procedure. While these bruises usually disappear within a few weeks, they may leave permanent scars in some cases, especially in individuals with sensitive skin.
10. ** Psychological Effects **
I understand that psychological discomforts such as fear of seeing blood, experiencing pain, or getting an infection may occur. These emotional effects can be more pronounced for those undergoing cupping for the first time.
11. ** Blood Disorders and Other Health Issues **
I acknowledge that cupping can be dangerous for individuals with bleeding disorders, such as hemophilia, due to the risk of excessive blood loss. Additionally, cupping can exacerbate the health conditions of individuals with chronic illnesses.
** Health Declaration **
Please check the boxes to indicate that you do not have any of the following conditions::
** Cupping (Hijama) Therapy Pre and Post Instructions **
Cupping (Hijama) Therapy I agree to follow the instructions below before and after the treatment.:
** Cupping (Hijama) Therapy Before: **
** Cupping (Hijama) Therapy After: **
** Additional Precautions and Information **
** Consent and Acknowledgement **
By signing below, I confirm that I have been informed about the risks and harms mentioned above and that I accept these risks. I also declare that I am signing this form of my own free will. I accept that I will not hold the cupping studio liable for any adverse events that may occur during or after cupping therapy.
