Red Light Health Agreement

Red Light Health Agreement

Be sure that the information you give is accurate and complete. All the information submitted shall be encrypted, and strictly used only in compliance to the law, guidelines, and ordinances, in relation to business operation.
Name*

First NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergeny Contact Information:
Name*

First NameLast Name
Relationship to Patient:*
Phone Number*
Please enter a valid phone number.
How did you hear about us?
Safety Notice:

The statements of this establishment have not been evaluated by the FDA. The information provided is not intended to diagnose, treat, cure, or prevent any disease and should not be construed as medical advice. Our products/services are low-risk, general wellness / fitness products that do not require FDA clearance, in accordance with the “General Wellness: Policy on Low-Risk Devices”.

Looking directly into the bulbs of the device can lead to adverse effects. Our office advises that you advert eyes, close eyes, and/or wear the optional eye coverings in order to avoid this.

We are not responsible for or injury or noncompliance.

By signing, you acknowledge the following:

I understand that if I sign up for the subscription, I will be billed every month on the same day I signed up. Example, signing up on May 15th will result in being charged on the 15th of the month, every month, until cancelation. The subscription is nonrefundable after the charge has gone through. A subscription can be cancelled only by contacting our office.

I have read the disclosure, understand all risks, and give my consent to be treated.
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Signature*

Clear
Should be Empty:

Red Light Health Agreement

Emergeny Contact Information: