Consultation form

Consultation Form

Prior to completing the consultation form, please make sure that your deposit has been paid.

Full Name

Date of Birth

Address

Email Address

Mobile Number

Medical History

Any Medication

Allergies or Skin conditions

Recent Surgery

Reason for Treatment

Where Did you hear about us?

Consent

I hereby provide my consent to undergo Hijamah and/or manual therapy treatment, including, but not limited to, sports massage, Gua sha, and/or fire cupping. I am aware that like any other treatment method, there are potential risks and side effects associated with the procedures. These risks include the slight possibility of infection, scarring, post-treatment soreness, lethargy, and fainting. I understand that I may experience some discomfort during the treatment and retain the right to discontinue the treatment at any point if I wish to do so. I also acknowledge that combining cupping with aggressive exfoliation is not recommended. For the next 24 hours after the treatment, I should avoid hot showers, baths, saunas, hot tubs, and intensive exercise. Additionally, I should limit caffeine and alcohol intake while ensuring adequate water consumption. I take full responsibility for this decision and absolve the practitioner of any liability for potential injuries or other outcomes resulting from the treatment. Before undergoing Hijamah treatment, please be aware of the following: Avoid Hijamah if you plan to start a new medication or receive a vaccination within the next 7 days. If you have recently started a new medication or had a vaccination, wait 14 days before receiving Hijamah. While Hijamah is generally safe and has been used for centuries, there are some side effects you should understand. Hijamah treatment will leave incision marks and circular discolorations on your skin, resembling bruises. These marks can last from a few weeks to several months, and in some cases, they may become permanent. You may experience discomfort due to the method of skin cuts during the treatment. Some patients may feel worse for a few days afterward, with an increase in pain in certain areas as the body adjusts and recovers. Please note that there may be unknown side effects, and the Hijamah therapist cannot accept liability for any illness, injury, or other untoward occurrence, except in cases of negligence resulting in death or personal injury. It is essential to provide accurate information about your medical history and current condition. False information may jeopardize your safety and the therapist's well-being.

Consultation form

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