Toxin Pulling Intake Form

Toxin Pulling (Wet Cupping / Hijama) Intake Form

Please take a moment to fill out the form below. It covers some important details about Toxin Pulling (Wet Cupping/Hijama), contraindications, post-procedure care, and waivers.

Your input helps us prepare for your session. We appreciate your cooperation.

About You

First Name *

Last Name *

Email Address *

Home Address *

City *

State *

ZIP / Postal Code *

Phone Number *

Biological Gender *MaleFemale

Age *

Occupation *

Job Title *

Disclosure

BENEFITS OF TOXIN PULLING (WET CUPPING / HIJAMA)

Toxin Pulling (Wet Cupping/Hijama) this Spiritual experience, has stimulating and strengthening effects so it can possibly assist with the following conditions and much more:

Constipation and Diarrhea
Sciatica
Headaches
Common cold and flu
Back pain
Skin problems
Arthritis
Weight loss
Period pain
Blood Stagnation
Injuries
Beauty therapy
Asthma
Immunity
Cellulite
Circulatory system
Fatigue
Gastrointestinal Disease
Anemia
Urinary disease
Depression
Psychological disease
Emotional problems
Hormone balance
Atrophy (loss of muscle)
Metaphysical concerns

CONTRAINDICATIONS (BETTER TO AVOID)

If you are on or have any of the following listed below, Soul Detox Inc. advises you to consult a knowledgeable Physician who is familiar with Toxin Pulling (Wet Cupping / Hijama) before having Toxin Pulling (Wet Cupping / Hijama) performed on you.

Blood Thinners (Don't take before Toxin Pulling (Wet Cupping/Hijama). Take immediately after session)
Skin disease (During Inflammation)
Pregnant
Menstruation
Under 18

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BEFORE TOXIN PULLING (WET CUPPING/HIJAMA)

Do not eat for 2–4 hours before your session.
Do not smoke or vape before Wet Cupping (Hijama).
Avoid caffeine before Toxin Pulling (Wet Cupping / Hijama).
Keep physical activity light on the day of your session: no training, no running, no spousal intimacy.
Keep your body warm.
Remove hair from the cupping site. (Grooming is an additional cost.)
Take a warm shower before Toxin Pulling (Wet Cupping / Hijama). This is ideal but not mandatory.

(Some of these are for best case scenario in order to yield the maximum benefits)

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AFTER TOXIN PILLING (WET CUPPING/HIJAMA)

Don't eat till 1 hour after Toxin Pulling (Wet Cupping/Hijama)
Eat a healthy, clean, high fat & high protein meal (1 hour after Toxin Pulling (Wet Cupping / Hijama)
Don't drink caffeine till 1 hour after Toxin Pulling (Wet Cupping/Hijama)
Keep Toxin Pulling (Wet Cupping/Hijama) sites warm. NO direct air hitting it, please!
(Where Toxin Pulling (Wet Cupping/Hijama)
Ideal to keep Toxin Pulling (Wet Cupping/Hijama) sites dry for a full 24 hours (Can shower but do not put soap on Toxin Pulling (Wet Cupping/Hijama) marks)
Don't sleep after Wet Cupping (Hijama), but if you find yourself tired then you can sleep.

Use Soul Detox Post-Toxin Pulling (Wet Cupping/Hijama) After Care Oil on Cupping sites to keep clean or coconut oil, black seed oil, tea tree oil, or olive oil.

What to expect after Toxin Pulling (Wet Cupping/Hijama):

Can possibly feel light-headed, sick/nauseous (especially in the morning on an empty stomach), fainting due to seeing blood. These cases are very rare and only occur if the client is unwell. Expect some Cupping Marks due to the nature of the suction from Toxin Pulling (Wet Cupping/Hijama) which goes away after a few days.

If at all there is no direct effect of Toxin Pulling (Wet Cupping/Hijama) on a particular disease (due to lack of research in that area Toxin Pulling (Wet Cupping/Hijama) is very beneficial for the spiritual treatment as it strengthens the immune system, activate lymphatic system, increase the blood circulation, purifies the blood, and removes toxins.

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SHOULD A "HEALTHY" PERSON DO TOXIN PULLING (WET CUPPING/HIJAMA)?

Toxin Pulling (Wet Cupping/Hijama) gets rid of acidic toxic waste which accumulates in our bodies (blood stasis) as we grow older.

Sources of toxic waste include the polluted air we breathe; toxic chemicals found in your food, water, drinks, household chemicals & toiletries; environmental waste in your neighborhood; intoxicating drinks, narcotic drugs, junk food, and smoking; waste products of normal body metabolism; products of medicinal drugs metabolism; the impact of trauma and accidents on our body; and toxins from mental stress, anger, anxiety, and depression.

The blood stasis (stagnated or congested blood) slows down or blocks the supply of blood via blood capillaries which deliver much-needed oxygen, nutrients, water, mineral electrolytes, vitamins, enzymes, hormones, and immune system cells & antibodies to your cells, tissues and organ.

The blockage also prevents the removal of carbon dioxide, metabolic waste products, and toxic substances which are excreted via our urine, lungs, and skin.

As a result, your cells, tissues, and organs cannot function at their normal healthy level and become progressively weak, inefficient, and easily overcome by germs.

This would cause tissue or organs to malfunction and infection to take place. Therefore you will experience symptoms of diseases such as aches and pain, numbness, fever, cough, stomach ache, constipation, diarrhea, and headaches.

If left neglected, further accumulation of toxic waste may lead to serious chronic diseases including hypertension, ulcers, diabetes, arthritis, Alzheimer disease, migraine, heart disease, stroke and cancer. Toxin Pulling (Wet Cupping/Hijama) is a very good preventive measure.

Initials Here *

Disclosure, Waiver, Acknowledgements, Cancellation & Photographs

DISCLOSURE & WAIVER FORM

We at Soul Detox Inc. are required to Spiritually practice CTPWCHP (Toxin Pulling (Wet Cupping/Hijama) Cupping Therapy) within the Scope of Practice, as outlined and in accordance with the Codes and Ethics of the Pastoral Medical Association, USA & Canada.

As a CTPWCHP (Certified Toxin Pulling (Wet Cupping/Hijama) Practitioner), I am not trained or qualified to diagnose, cure or prescribe medication to my clients.

I am not a qualified and licensed Master Personal Trainer
I am not a qualified and licensed Medical Doctor
I am not a qualified and licensed Registered Nurse Practitioner
I am not a qualified and Licensed Acupuncturist/Chinese Medicine Practitioner
I am not a qualified and Licensed Massage Therapist (LMT)
I am not a qualified and Licensed Naturopathic Doctor
I am not a qualified and Licensed Herbalist
I am not a qualified and Licensed Nutritionist
I am not a qualified and licensed Physiotherapist

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ACKNOWLEDGEMENTS

I acknowledge and agree that the professionals at Soul Detox will determine the appropriate number of cups for my body, based on their expertise and assessment.
I understand that during toxin pulling (wet cupping/hijama), the volume of stagnant blood released may vary due to individual factors beyond control.
I understand that the color of the cupping marks on my body may vary based on how my body responds, and this is not something that can be controlled.
I confirm that I do not have a phobia of scalpels.

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CHP WAIVER FORM

I have been informed by the CTPWCHP, understand and accept the following:

That CTPWCHP is not a recognized, approved and regulated medical procedure. It is a spiritual healing method to relieve various conditions in the mind, body, and soul of the Client. It can also relieve metaphysical concerns.
I understand that I may not see the full benefits after Toxin Pulling (Wet Cupping/Hijama) and it may take more than 1 session to see any improvements in overall wellness.
The CTPWCH can not diagnose me, cure me, or prescribe medications to me (unless they actually are a formally trained and qualified Medical/Health Professional and licensed by a recognized Authority).
CTPWCHP is a natural detoxification process that cleanses the body on a cellular level. A small amount of toxic blood is extracted from the skin by grazing the skin surface with a size 15 single-use sterile surgical blade. Toxin Pulling (Wet Cupping/Hijama) will be done and several, small, shallow grazes will be made upon my skin at the cupped Toxin Pulling (Wet Cupping/Hijama) sites to draw a minimal amount of toxic blood.
Toxin Pulling (Wet Cupping/Hijama) is a very safe Spiritual treatment with minimal after effects, and no liability cases to date.
That all blood items such as cups, blades, and tissues are single-use only and not to be reused by me or anyone else.
The CTPWCHP has fully explained the procedure, contraindications, outcomes, aftereffects, and post-care instructions of the Toxin Pulling (Wet Cupping/Hijama) procedure to me, shown me the equipment and I understand the process of Toxin Pulling (Wet Cupping/Hijama).
I give permission to the CTPWCHP to safely and professionally perform Dry and Toxin Pulling (Wet Cupping/Hijama) on my body, create several, small, shallow grazes by breaking the skin barrier with a size 15 single use sterile blade or with a diabetic needle and lancet within the circle of the Toxin Pulling (Wet Cupping/Hijama) site. Also, to clean me up, disinfect, sanitize, and seal me with oil.
Biological Females: I confirm I have taken a pregnancy test and confirm that I am not pregnant.

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PHOTOGRAPHY/ VIDEOGRAPHY:

Client agrees to full use of photography/video and/or photographs/videos taken during or after services to be used for Soul Detox portfolio and promotional images.

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CANCELLATION POLICY:

Cancel at least 24 hours in advance: No charge, and you will receive a full refund.
Cancel within 24 hours: A $50 fee will be charged.

LATENESS POLICY:

Arriving 10 minutes late: The full amount will be charged and your appointment time may be cut short.

NO SHOW POLICY:

If you do not show up for the appointment: The full amount will be charged.

Please arrive 10-15 minutes before your scheduled appointment. Should you need to cancel or schedule your appointment please notify us 24 hours prior. Any cancellations are subject to a $50 fee. Clients who miss appointments without prior notification will be charged for the full service. Clients who are late greater than 9 minutes are subject to having their service canceled or shortened. You will also be charged the full amount of that service. We require that Credit card information be on file to guarantee your reservation.

Initials Here *

I have read and agree to the terms and conditions, and I acknowledge the rare potential for blistering during the procedure. *Click here to accept

Anything else you'd want us to know before your appointment?