Cupping intake/ consent Form Name * First Name Last Name Pronouns Email * Phone * (###) ### #### Date of birth * MM DD YYYY Emergency contact (name/relationship/phone #) * How did you hear about us? What would you like to achieve with your cupping session(s)? ABOUT FACIAL CUPPING: * Facial cupping uses gentle negative pressure on the skin with a silicone facial cup. The suction draws blood flow towards the surface of your skin. This increased blood flow in the skin underneath the cup and surrounding the tissues encourages the formation of new blood vessels. The suction prompts a natural healing process in the skin, more oxygenated blood flows to the area, collagen and fibroblast production is stimulated, and the skin cells are encouraged to reproduce. I understand that the suction created by facial cupping might result in a local mark on the face that might occur from the release and clearing of stagnation of toxins in the body I understand that this reaction will dissipate within few hours to a few days. I understand my Esthetician is trained in facial cupping and will do everything possible to avoid these marks. I understand that facial cupping is most effective when done consistently alongside proper home care. I agree to inform my Esthetician if I have/or am (check boxes if it applies to you): * Botox/ fillers Very thin skin that bruises easily A history of allergic reactions Skin cancer I also agree to inform my practicioner about any chronic illness as well as any medication I'm currently taking Migraines Skin easily reddens Pregnant Painful/ uncomfortable acne List any chronic illness as well as any medication currently taking: CONSENT: * I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that Esthetics/ Skin care therapy cannot cure, treat, prevent or diagnose conditions. These treatments are used as regimens for improving skin appearance and wellness. I furthermore understand that Esthetics should not be considered a substitute for medical examination and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. Any information exchanged during a skin treatment session is confidential, should be given at my own discretion and is only used to provide the best skin care treatment. If I experience any pain, discomfort or experience any complications I will discuss them with my Esthetician immediately so that the products and/ or techniques may be adjusted to my level of comfort. I understand that withholding any information or providing misinformation may result in contraindications and/ or irritations of the skin from treatments received. I understand that everyone's skin is different and irritations may occur. The Esthetician reserves the right to refuse service to anyone for any reason. I understand that there is a $30 same day cancellation fee and as a courtesy I will allow 48 hours for appointment changes or cancellations. I understand that the proper client care requires the full amount of time allotted for visits, and that if I arrive more than 10 minutes I may need to reschedule or pay the $30 same day cancellation fee. By checking the box below I acknowledge that I have read and understand all parts of this consent/ intake form and that I have had the opportunity to ask any questions with regards to any services offered. I release Touch of Radiance, LLC. and any of its Estheticians from any liability. I understand and agree Thank you!