LED Therapy Consent Form

NOTE: This form is required to be filled out prior to a client's first LED Therapy treatment at Simply You Skincare & Wellness.
LED Therapy Consent Form

Simply You Skincare & Wellness
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Name*

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Although every precaution will be taken to ensure your safety and wellbeing before, during and after your LED treatment, please be aware of the following information and possible risks.
- Clients who have had LASIK may have increased sensitivity to the treatment.
- Reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations.
- Some clients report slight tingling sensations and flashing of the optic nerve during the procedure.
- Additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
Is Satisfaction Guaranteed?

The majority of my clients receive satisfactory to above average results with a series of treatments. Maximum results are highly dependent on your age, cumulative sun exposure, health, menopause, lifestyle, genetic traits, general skin condition, and your willingness to follow recommended protocols.

Contraindications

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for LED therapy treatment and must be disclosed prior to treatment:
- Epilepsy
- Medications causing light sensitivity
- Open wounds
- Pregnancy
- Thyroid conditions
- Optic nerve damage or sensitivity
I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand that if I have any concerns, I will address these with my esthetician. I give permission to Allie Bebenroth (esthetician) to perform the LED procedure we have discussed, and will hold her harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.*

I agree
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