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Fire Cupping

 Client Waiver

Please fill out the following form
in order to participate in our activity.

Disclaimer and Informed Consent for Suction/Fire Cupping Therapy

I, a client of Traditional Thai Massage, hereby acknowledge that I have voluntarily chosen to undergo fire cupping therapy at Traditional Thai Massage, located at 109 Parkers Walk, Newmarket. I understand that fire cupping therapy involves the application of heated cups to my skin, which creates a vacuum effect and may result in various sensations and potential risks.


I acknowledge the following:

  1. No Insurance Coverage: I am aware that Traditional Thai Massage does not carry insurance coverage specifically for fire cupping therapy. Therefore, any potential risks or complications arising from this therapy will not be covered by insurance.

  2. Possible Side Effects: I understand that fire cupping therapy may result in temporary skin discoloration, bruising, or soreness. While these effects are generally mild, they are considered normal and are usually temporary.

  3. Burn Risk: Fire cupping involves the use of heated cups, which can potentially cause burns if not applied or removed correctly. Traditional Thai Massage takes precautions to minimize this risk, but I acknowledge the possibility.

  4. Health and Medical History: I have provided accurate information regarding my health and medical history to Traditional Thai Massage, including any pre-existing medical conditions, allergies, or medications I am currently taking.

  5. Informed Choice: I have had the opportunity to ask questions and seek clarification about fire cupping therapy. I am making an informed and voluntary decision to undergo this therapy.

I understand that fire cupping therapy is not a replacement for medical treatment, and it is not guaranteed to provide specific health benefits.

By checking the box below, I acknowledge that I have read and understood the above information, and I consent to receive fire cupping therapy at Traditional Thai Massage. I release Traditional Thai Massage, its employees, and practitioners from any liability related to the therapy and any possible side effects or injuries that may occur.

Thanks for submitting!

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