Cupping Therapy Consent Form

Section 1: Basic Information

Date

How did you hear about us?

Is this form being filled out for a minor (under 18)?

No Yes

First Name

Last Name

Preferred Name / Nickname

Date of Birth

/ /

Gender at Birth

Soc. Number

Referred By

Mobile Phone

Address 1

Address 2

City

State

Zip Code

Emergency Contact Name

Emergency Contact Phone

Which location are you visiting?

Is this your first visit to a Be Well Center?

Insurance Info (If Applicable)

Upload License Choose file

No file chosen

Upload Insurance Card Choose file

No file chosen

Are You Self Insured or through another Individual?

If Insured through another Individual, Please enter the Following Information:

First Name

Last Name

Sex

Relationship to Patient

Date of Birth

/ /

Address

Phone Number

Section 2: Medical History

Primary reason for seeking cupping therapy

Areas of pain or discomfort

How long have you had these symptoms?

Current pain level

List all medications (or leave blank if none)

Are you taking blood thinners?

Are you pregnant?

Medical Conditions (check all that apply)

Diabetes

Heart Disease

Blood Disorders

Skin Conditions

Cancer

Autoimmune

Known allergies (or leave blank if none)

Section 3: Cupping-Specific Information

Have you had cupping therapy before?

Do you have sensitive skin?

Do you bruise easily?

What areas would you like treated?

Skin Conditions (check all that apply)

Eczema

Psoriasis

Dermatitis

Rashes

Sunburn

Open Wounds

Recent Scars

Varicose Veins

Skin Cancer

Any areas to avoid?

Anything else we should know?

Section 4: Consent & Signature

I have read, understand, and agree to all of the above

Full Legal Name (This acts as your electronic signature)

I agree that by typing my name above, I am electronically signing this form. I understand that my electronic signature is legally binding and has the same legal effect as a handwritten signature, pursuant to the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN) and applicable state laws.

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Please complete all sections of this form.