Cupping Consent Form Template
A free cupping consent form for wellness spas, massage and holistic practitioners. Clients share health notes, learn about marks and sign before treatment.
Customize the pages and design to fit your needs.
About this template
A cupping therapy consent form with a short health check, the areas to treat and sample terms about marks, aftercare and stopping at any time. Clients sign online and you keep a signed PDF.
Common uses
- Wellness spas
- Massage therapists offering cupping
- Holistic practitioners
Key features
- Treatment areas
- Health check before treatment
- Signed consent as a PDF
What this template asks
What's your full name?
Short Text
What's your email address?
Email
What's your phone number?
Phone
Have you had cupping before?
Yes / No
Which areas would you like treated?
Multiple Choice · Upper back, Lower back, Shoulders, Neck, Legs, Not sure
Do any of these apply to you?
Multiple Choice · Optional · Pregnant, Taking blood thinners, Skin condition or sunburn, Bleeding disorder, Recent surgery, None of these
Is there anything else your practitioner should know?
Long Text · Optional
Cupping consent
Agreement text, accepted with “I agree”
Sign the cupping consent
Signature
How to use this template
Copy it
Select Use template and a copy opens in your workspace as an unpublished draft.
Make it yours
Edit any question or answer, choose a theme, and add your logo.
Share it
Publish, then send the link, show a QR code, or embed the form on your site. Responses arrive in Submissions.
Cupping consent
Signers read this text in the form before they accept it. Edit the bracketed details to match your business, and have the wording reviewed for your situation.
Please read this before you sign.
This agreement is between [Business name] (the "Practitioner") and the client named in this form.
- What cupping is. Cups create suction on the skin for relaxation and muscle tension. It is not medical care and does not replace care from a doctor.
- Marks. Cupping often leaves round marks that can last [number] days. They are expected and usually fade on their own.
- Other effects. The client may feel tender, tired or lightheaded after treatment.
- Health. The client has shared any health details that matter and will tell the Practitioner if anything changes.
- Stopping. The client may ask to lower the suction or stop treatment at any time.
- Aftercare. The client will follow the aftercare advice given, such as drinking water and keeping the area warm.
By signing below, I confirm that I have read this consent and agree to it.
Frequently asked questions
What should a cupping consent form include?
A health check, areas to treat, and terms about marks, other effects, stopping at any time and aftercare. This template includes each one as a sample to start from, not legal advice.
Who uses a cupping consent form?
Wellness spas, massage therapists and holistic practitioners who offer cupping, on its own or as part of a massage.
Can clients sign before they arrive?
Yes. Send the link with the booking confirmation so clients sign at home, and your practitioner reads the notes before treatment.