Home Phototherapy Instructions Form for Kaiser Patients

Home Phototherapy Instructions Form for Kaiser Patients
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Which device did you order for this patient?
Model*
Controller:
Time Only

Lamp Rx:
Narrowband UVB
What is the treatment protocol for this patient?
Beginning Treatment Dose*

Skin Type I & Vitiligo (200mJ)Skin Type II (300mJ)Skin Type III (400mJ)Skin Type IV (500mJ)Skin Type V (700mJ)Skin Type VI (800mJ)Other
Treatment Schedule*

3 times per week (i.e. Mon-Wed-Fri)Other
If symptoms last less than 24 hours, adjust treatment by:*

Increase by 10%Increase by 15%Other
Special Instructions
Important! Please read the Operation Manual that comes with your home phototherapy unit before use.
Treatment Goal

Your treatment goal is to experience a light pinkness, warmth, tenderness, or tingle that lasts less than 24 hours. If redness occurs, call your provider.
Treatment Plan for Patients with Timed-Mode Devices
- Use the beginning dose above and the lamp output from your calibration certificate to find your first treatment time on the UVB time chart.
- Follow the frequency and increase advice recommended by your provider (above). If symptoms remain at the time of the next treatment, do not increase the dose. Keep it the same each treatment until symptoms no longer last more than 24 hours, then resume increases as normal. Use a Treatment Log to track progress.
- Each treatment time is for one (1) exposure. Repeat the treatment time for each separate body area.
Helpful Tips for DermaPal Users

Use the comb attachment as a distance guide.

Training Videos for DermaPal Users

Understanding Your Doctor's Treatment Plan (video)

How to Unlock Your DermaPal (video)

How to Operate Your DermaPal (video)

How to Enter a Treatment into Your DermaPal (video)
Helpful Tips for 1 Series Users

Palms/soles may rest on the acrylic. Do not stand on unit. Other areas can be reated at a 9 inches. Always be sure you are using the proper lamp output for the area you are treating (on surface vs. 9 inches away).
Helpful Tips for 4 Series Users

Stand 9 inches away from the lamps.
Helpful Tips for 7 Series Users

Stand 9 inches away from the lamps.
Protecting Non-Treated Areas

Always use the following to protect areas that are NOT being treated:
- UV blocking goggles (included)
- Sunscreen (if directed by provider)
- A towel, pillowcase, paper bag, or mask to cover face; clothing to cover other untreated areas of the body
- Protection for the genital area
Note: Anyone providing assistance to patients during treatments, such as guardians or home healthcare nurses, should also protect their skin and wear UV blocking goggles. Please visit the Accessories Order Form to purchase additional pairs of UV blocking goggles.

Medications and Topicals

Some topicals may hinder treatment (e.g. lotions containing UV absorbing ingredients similar to those used in sunscreens). Other topicals and medications may photosensitize your skin, for example, lotions containing photosensitizing agents or essential oils such as lime, lemon, or orange. Such ingredients could cause an unexpected erythemal reaction when exposed to the ultraviolet energy delivered during a phototherapy treatment. In addition, coal tar, psoralens, and retinoids will consistently photosensitive your skin to UV light. We strongly recommend speaking with your provider about topicals and medications that may impact your phototherapy treatments.

Missed a Treatment?

Use the guidelines below to determine what to do next:

Missed for 1 week	Keep dose the same (no increase)
Missed for 2 weeks	Reduce the dose by 25%
Missed for 3 weeks	Reduce the dose by 50%
Missed for 4 weeks	Restart at the beginning dose above

Additional Instructions (if applicable)
Training Videos
Training Videos for Timed-Mode Devices

Understanding Your Doctor's Treatment Plan (video)

How to Use Your Device's Controller (video)

See Daavlin's Youtube channel for more helpful videos.
Signature

By entering your name and submitting this form, you hereby confirm the above information is accurate and complete to the best of your knowledge. You also certify that you have obtained consent from the patient listed above to communicate using the email provided in this form for training purposes. Your patient will receive a copy of this form, along with training videos. If your patient needs additional assistance, they will be provided with a link or QR code to book a phone training appointment with a customer service representative.
Physician's Name*

First NameLast Name
Physician's Email*
We collect your email address for the purpose of sending you a confirmation of your treatment plan and training submission. Your email address will not be shared with anyone.
Physician's Signature*

Clear
Date*

MonthDayYear
FRM-00138 [0]
Should be Empty:

Home Phototherapy Instructions Form for Kaiser Patients

Which device did you order for this patient?

What is the treatment protocol for this patient?

Special Instructions

Training Videos

Signature