AMOM Online Intake Forms โ€“ Fire Cupping & Herbal Bath

Acupuncture and Massage School of Oriental Medicine (AMOM)

28446 Franklin Rd, Southfield, MI 48034 ยท (248) 434-8588 ยท amomschool.org
Health Screening (check all that apply)
Absolute Contraindications (must answer)

Important: If any item above applies, you may be not eligible for fire cupping today. Practitioner will assess and may refuse treatment for safety.

Postโ€‘Treatment Care: Do not shower, bathe, or swim for 24 hours after treatment; avoid cold wind/AC; hydrate with warm water or tea; avoid alcohol/spicy food and strenuous exercise for the day.
Consent, Risk Acknowledgment & Liability Waiver

I understand fire cupping is a traditional therapy and not medical care. Potential risks include bruising, blistering, or burns. I have truthfully disclosed my health information and consent to treatment. I assume all risks and release and hold harmless AMOM, its students, instructors, supervisors, and affiliates from any and all claims or liability arising from this treatment. Results are not guaranteed.

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