WILLIAM BLANE RICHARDSON, MD

| SOUTHERN GRACE PRECISION & AESTHETICS

WILLIAM BLANE RICHARDSON,MD

SOUTHERN GRACE PRECISION & AESTHETICS

CUPPING THERAPY

SCHEDULE

YOUR CONSULTATION TODAY

You have both the right and responsibility to make decisions concerning your healthcare. The physician shall provide you with the necessary information, but, as a member of the healthcare team, it is essential that you enter into the decision-making process. This form has been designed to document your informed consent to the procedure(s) that you have discussed with your physician.
I hereby authorize Dr. Blane Richardson to perform the cupping therapy.
ABOUT CUPPING THERAPY

  • Cupping therapy utilizes negative pressure, rather than tissue compression, for superior results when integrated into a massage session and other bodywork modalities. Cupping therapy is a traditional treatment used by millions of people worldwide because it’s safe, comfortable and remarkable results.
WHY CUPPING IS SO EFFECTIVE IN BODYWORK?

  • By creating suction and negative pressure, cupping therapy lifts connective tissue. This negative pressure can release rigid tissue and loosens adhesions.  Cupping pulls stagnation, waste, and toxins to the skin level where it can be easily flushed out by the lymphatic and circulatory systems.
  • Cupping techniques bring fresh blood flow and nutrition to stagnant areas. The pulling actin engages the parasympathetic nervous system, thus allowing deep relaxation throughout the entire body.
  • Cupping therapy, when integrated with massage and bodywork, can be far more effective and long lasting than any other therapeutic bodywork applied alone.
WHAT ARE THE MARKS THAT CAN OCCUR FROM CUPPING?

  • With deeper cupping techniques bruising may occur. The marks that are created with the application of the cups are an indicator of the “therapeutic trauma.”  They are metabolic waste, toxins and other stagnant materials that have been freed from the underlying tissue, brought to the surface where they can more easily be flushed away.  The color can vary from a bright red to a deep purple-black.  These marks can last anywhere from a few hours to a few weeks and may be tender to the touch immediately after a session.
  • As treatment continues, the marks will occur less and less as a result of stagnation and toxicity being expelled from the body.
CONTRAINDICATIONS

  • Severe Disease * Hernia * Fever * Fractures
  • Cancer * Hemophilia * Herniated Disc * Sunburn
  • Edema * Varicose Veins * Phlebitis * Renal Failure
  • Cirrhosis * Heart Disease * Diabetes * Energy Depleted Clients
  • Blood Thinners * Pregnancy (abdominal, low back and lower leg)
  • Uncontrolled Hypertension

I  understand that bruising, discoloration and/or soreness may occur following this treatment and may take days or weeks to fully resolve.  I understand that cupping treatments can be a “detoxifying” treatment process and as a result I may feel nauseated or unwell following treatment.  Drinking water and taking Vitamin C has been reported to relieve these symptoms quickly.  In some cases, headaches and minor body aches may be experienced.  I further understand that the above-listed conditions are contraindications for cupping therapy and I have informed my provider of any and all medical conditions, even those not listed as contraindications.

This consent has been translated to me in
I, the patient, have had the opportunity to ask questions and wish to proceed with the planned procedure.
I have read and fully understand this form and understand that I should not sign this form if all items, including my questions, have not been answered to my satisfaction or I do not understand any of the terms or words contained in this consent form.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED PROCEDURE OR TREATMENT, OR QUESTIONS CONCERNING THE PROPOSED PROCEDURE OR TREATMENT, ASK YOUR PROVIDER NOW, BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM UNLESS YOU HAVE READ AND THOUROUGHLY UNDERSTAND THIS FORM.
Patient Address


PROVIDER DECLARATION: I have explained the contents of the document to the patient and have answered all the patient’s questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented
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