Hijama USA Consent Form

I understand clearly that Hijama is a prophetic treatment and is in no way intended to treat, cure, or heal symptoms or diseases. Its purpose is to revive the Sunnah of the Prophet Muhammad ﷺ

I confirm that I am:

• An adult over the age of 18 (if under 18, a parent or guardian must provide consent below)

• A mature and mentally competent individual, fully capable of making my own decisions.

I give complete consent and permission to Rizwan Sheikh & Saima Sheikh from Hijama USA LLC, or any other certified person by Hijama Nation and the Professional Wellness Alliance to perform hijama/wet cupping on me or my family member.

I understand that by consenting to the cupping procedure, I may encounter certain risks or side effects, including but not limited to:

• Mild discomfort and pain

• Light bleeding

• Infection risk if I scratch or irritate the cupping area

• Healing crisis (see our FAQ section)

I declare that I assume the risks of the hijama procedure stated above, as well as any other risks listed on the Hijama USA: www.hijamausa.com

I understand that hijama is spiritual and religious treatment and should not be considered medical treatment. For any medical treatments or emergencies, patients should consult their Primary Care Physician (PCP).

I acknowledge the instructions and will fast for 3 hours, avoiding both food and water, prior to my appointment.

I acknowledge that this consent form will stay in effect for all future visits and at any location.