LTW INTERNATIONAL

Basic consent for LIGHTWAVE Therapy

You have chosen, after consultation with your doctor/esthetician, to undergo LIGHTWAVE Therapy. The purpose of this treatment is for

Items to consider before LIGHTWAVETM Therapy:

1.It is important to tell staff if you are pregnant, diabetic, taking antibiotics, or have cancer.

2. The final results may not be apparent for several weeks after the treatments.

3. Sun bathing, alcohol consumption, smoking and eating habits directly affect outcome of the treatment. Remember to eat well and limit sun bathing, alcohol and smoking to a minimum.

4. Drink at least 8oz of water before and after the treatment.

5. Do not apply creams, moisturizers or antiperspirants before a treatment.

6. It is important to notify the clinic if there are any problems or concerns after the treatment, including prolonged redness.

7. The fee is paid for the treatment itself. Results vary depending on lifestyle habits and genetics so there is no guarantee that the expected or anticipated results will be achieved.

8. More than one treatment package may be required. There will be a charge for each treatment.

My signature verifies that I have read and understand the goals, limitations, risks, and possible side-effects to the treatment, and that I have been given the opportunity to ask questions. My signature also verifies my informed decision to proceed with LIGHTWAVETM Therapy and have the treatment. I additionally, consent to the taking of photographs during thecourse of my LIGHTWAVE Therapy for the purpose of medical education.

Patient Name*

Patient Signature (or legal guardian)*

Date*

Date

Basic Consent Form Last revised: 0318