Medical Form

Please fill out this medical history form to the best of your knowledge prior to your appointment. All appointments require this form to be completed. 

I understand that the medical information recorded in this form is for informational/ therapeutic use only and is strictly confidential. I understand that I must consult with my Medical Doctor if I currently have or develop any of the abovementioned conditions, before I can commence with anybody and energy work. I understand that the practitioner may combine therapies and tailor-make a treatment package for which could include any or all of the treatments: Hijama (Dry/Message/ Wet). • The Practitioner has explained the procedures for all of these treatments. I understand that there will be usage of a surgical blade and blood work during the WET CUPPING procedure. • I give permission to the practitioner to use a small, surgical, incision blade on my body in order to scratch the surface of the skin and draw a small amount of toxic blood according to their professional discretion. I understand that results my not be immediate after each therapy. I take full responsibility for my treatment and have chosen to undertake the Hijama Cupping Therapy. • I Agree to be punctual according to my appointment time, give 24 hours notice before a cancellation and pay a full session’s fee if I do not attend my appointment without prior notice. 

CONTRAINDICATIONS: Hijama Cupping Therapy can affect the following list of conditions. All Clients must seek medical advice from their Doctor before commencing treatment sessions. All body and energy work will be practiced at the therapist’s discretion, according to the illness, conditions and stress levels that the client presents with. Diabetes Cancer Cuts/Abrasions Undiagnosed lumps on body Thrombosis/ Embolism Lacerations/ Ulcers Early stages of Labor Recent Injuries/ Surgery Warts/ Skin tags Memory problems Epilepsy Current Fractures Recent Sprains/ Strains Heart Conditions Nerve Dysfunction Ingrown toenails Contagious Diseases Recent Hemorrhage Moles Mood Severe Edema Active Shingles Skin Disease/ Disorders High/ low Blood Pressure Varicose Veins Gout Post- Operation of an Organ transplant Sunburn/ Windburn Bone Fractures Bleeding disorder