Aurora Chiropractic IASTM/Cupping Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Instrument Assisted Soft Tissue Mobilization (IASTM) is an instrument assisted variation of traditional cross fiber or transverse friction massage. The instruments are used to "break up" or "soften" scar tissue, thus allowing for the return of normal function in the area being treated.

IASTM may produce the following:

1. Local discomfort during the treatment

2. Reddening of the skin

3. Superficial tissue bruising

4. Post treatment soreness

The above reactions are normal and in some instances unavoidable.

Cupping is a therapy that applies negative pressure on the skin using plastic or silicone cups. The suction created by these cups stimulate and increase blood flow, which can help relieve joint and muscle pain, reduce inflammation, and accelerate recovery.

We do not recommend cupping or instrument assisted soft tissue mobilization in these cases:

1. Skin lesions

2. Organ Failure

3. Pacemakers

4. Hemophilia or similar bleeding disorders

5. Cancer

6. Varicose veins or spider veins

Caution should be taken with the following conditions, please talk with your practitioner if you are experiencing any of these:

1. Diabetes with complications or acute infection

2. Taking anticoagulant medication (Aspirin, Warfarin, Etc)

3. Severe chronic disease such as Heart Disease

4. Pregnant, within 6 weeks of giving birth, or menstruating

5. Lymphedema or anemia

6. New tattoos (localized)

7. Recently donated blood or undergone a medical procedure

Email *

Do you bruise easily? *

Yes

Do you bleed for a long period of time after you cut yourself? *

Yes

Are you taking blood thinners or anticoagulants? (Aspirin, Warfarin, etc) *

Yes

Have you ever had inflamed veins or blood clots? *

Yes

Do you have surgical implants in your body? *

Yes

Do you have diabetes or kidney disease? *

Yes

Do you currently have any infections? *

Yes

Do you have uncontrolled high blood pressure? *

Yes

Please consent to treatment below: *

I understand these services may result in marks left on my body and these marks can take anywhere from a few hours to up to 2 weeks to resolve. These may look like a bruise.

I understand these bruises may be tender to the touch and I will inform my practitioner if I am uncomfortable any time throughout my treatment.

I understand and am aware that there can be side effects to cupping and instrument assisted soft tissue mobilization such as: nausea/vomiting, fainting, blisters/infections, bleeding, bruising, headaches, dizziness, fatigue, and others.

Required

Patient's Name: *

Today's Date: *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Aurora Chiropratic. Report Abuse

Forms