Cupping Hijama Directory of Practitioners Form

Please Complete the Following Form

If you wish to have a priority listing you must have read the Broken Earth Traditional Cupping (Hijama) Education Course and agreed to the terms as a signatory to the Broken Earth Standards and Practices.


Practitioners First Name:
Practitioners Last Name:
Business Name, If Any:
Address 1:
Address 2
City:
State/Providence:
Postal Code:
Country:
Primary Phone:
Secondary Phone:
Primary E-Mail:
Website URL:
What's This? E-Book Verification Code:
What's This? NSW Authorization:	Yes No
Broken Earth Standards & Practices:	I hereby attest before the Creator of All Things that I have read and will abide by the Broken Earth Standards and Practices set forth in the Traditional Cupping (Hijama) Education Course in the performance of cupping practices on all clients who seek my services as a cupping practioner. I have further read and understand the information contained in the Traditional Cupping (Hijama) Education Course. I also further agree to report any problems or unique discoveries about cupping that may help to better perfect the treatment provided to cupping clients.
I Have Read & Agreed to the Above:	Yes No
Agree With Noted Exceptions: What's This?
Other Qualifications:
Short Description of Other Services:

Thank you! After we review your listing we will include it in our directory and then notify you by e-mail. If you have any comments or suggestions please contact us. Please make sure to hit the Submit button only once.

E-Book Verification Code: When you order the Broken Earth Traditional Cupping (Hijama) Education Course you will receive a verification code or e-book access code that will enable you to download the e-book into your e-book reader. This code is the only way we have to ensure that you have read the course material. Ordering the course is optional but you will not receive a priority directory listing or signatory status.

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NSW Authorization: Authorization from a master who has been authorized by his master all the way back through a verifiable chain to the original Prophetic teaching and authorization. If you would like information on how you might receive this type of authorization, contact us for more information.

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Agree With Noted Exceptions: Many practitioners, especially those trained under the Chinese tradition may agree with most of what is set forth in the Broken Earth Standards and Practices but wish to take issue with one or more practices. If you agree with the bulk of the Standards and Practices outlined but take exception to certain requirements. Please indicate those exceptions or alternative approaches here. We will then include you as a Broken Earth signatory with the added exceptions available for clients to consider. We reserve the right not to provide signatory status to anyone we believe deviates from the standard practices to a point that, in our sole opinion and based on the authorized training we have received, might cause potential harm to the client.

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Suicide, Abuse, Divorce, Anxiety, Loss of a Loved One, Addiction, and Other Spiritually Rooted Disorders.