Cupping Therapy Waiver
Liability Release, Assumption of Risk & Informed Consent
This agreement ("Agreement") is entered into between [Business Name], located at [Street Address], [City], [ST] ("Provider"), and the undersigned client ("Client") in connection with cupping therapy waiver services. By signing below, the Client acknowledges that they have read and understood each provision herein.
1. Acknowledged Risks Specific to This Procedure
The Client understands that the following risks are inherent to this specific service and cannot be eliminated even with proper technique and care:
- Temporary round bruises (cupping marks) lasting days
- Skin irritation or, with fire cupping, burns
- Not suitable for fragile skin or bleeding disorders
- Marks may be visible on exposed skin
- A wellness service with no medical claims
2. Informed Consent to Cupping Therapy
The Client consents to cupping therapy in which suction cups are applied to the skin. The Client understands that circular discoloration (cupping marks) is an expected result and may remain visible for several days.
3. Cupping Risks and Marks
The Client acknowledges that cupping commonly leaves temporary round bruises and may cause skin irritation, and-where heat or fire cupping is used-carries a risk of burns. The Client confirms they do not have a bleeding disorder, fragile skin, or active skin conditions in the treatment area.
4. Assumption of Risk
The Client voluntarily elects to receive the services described in this Agreement with full knowledge of the inherent risks involved. The Client understands that no procedure is entirely without risk and that individual results, reactions, and tolerances vary. The Client knowingly and freely assumes all such risks, both known and unknown, even if arising from the negligence of the Provider, and assumes full responsibility for participation.
5. Release and Waiver of Liability
In consideration of being permitted to receive the services, the Client hereby releases, waives, discharges, and covenants not to sue the Provider, its owners, employees, and agents from any and all liability, claims, demands, or causes of action arising out of or related to any loss, damage, or injury that may be sustained while receiving the services, to the fullest extent permitted by law.
6. Medical History and Disclosure
The Client affirms that they have disclosed to the Provider all relevant medical conditions, allergies, medications, and prior adverse reactions. The Client understands that withholding such information may result in injury for which the Provider bears no responsibility, and agrees to promptly notify the Provider of any change to their health status prior to receiving services.
7. Indemnification and Hold Harmless
The Client agrees to indemnify, defend, and hold harmless the Provider from any loss, liability, damage, or cost, including reasonable attorneys' fees, that the Provider may incur as the result of the Client's receipt of services, whether caused by the negligence of the Client or otherwise.
8. Governing Law and Venue
This Agreement shall be governed by and construed in accordance with the laws of the state in which the Provider operates, without regard to its conflict-of-law principles. Any dispute arising under this Agreement shall be brought exclusively in the state or federal courts located in that state.
9. Data Privacy and Communications
The Client consents to the Provider collecting and storing the personal information provided herein for the purposes of service delivery, scheduling, and follow-up care. Information will not be sold to third parties. The Client may request access to or deletion of their records consistent with applicable law.
10. Severability and Entire Agreement
If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect. This document constitutes the entire agreement between the parties regarding its subject matter and supersedes all prior understandings, whether written or oral.
The Client affirms they are at least 18 years of age (or the parent/legal guardian of a minor participant), have had the opportunity to ask questions, and sign this release freely.
Client signature, printed name and date, and (for a minor) the parent or guardian's signature.