Red Light/ NBUVB Therapy Appointment

Name*

First NameLast Name

Your Birthday (must be over the age of 18)*

Date

What membership do you have?*

Platinum (red light therapy & NBUVB therapy included in membership) no feeDay Time Membership & Tanning/ Not included in membership ($5.00 Fee)Standard Membership ($5.00 Fee)Non Member ($10.00 Fee)

PLEASE NOTE: you must ask a staff member for the red light therapy room key upon arrival for your appointment (typically we are in the front, Cleaning or in the childcare center) if you are using NBUVB a staff member must set your timer. Members may set the red light therapy panel on their own only. TY- as we need to stay in compliance of all state and local laws.

Will you be using Narrow Band UVB lights with your secession?*

YesNo

Appointment*

If you are using narrow band UVB light therapy how many minutes do you want? (you may only schedule NBUVB appointments after 24 hours have passed from your last treatment secession) Secession appointments will be deleted and not approved if it has not been 24 hours from the last time you used the NBUVB lights.

What is Narrowband UVB (NBUVB) Phototherapy NBUVB treatment involves the exposure of skin to a special kind of ultraviolet light that has beenshown to be helpful for many patients with psoriasis, eczema, vitiligo, and other conditions.Benefits of NBUVB phototherapy: Potential improvement of your skin conditionPotential risks / side effects of NBUVB phototherapy: Some redness and dryness of the skin is to be expected. A reaction similar to a sunburn isanother risk of treatment. Over the long-term this can lead to premature aging of skin Possible increased risk of skin cancer, although it is generally believed that NBUVB therapyresults in fewer skin cancers than other forms of ultraviolet light therapy Cataracts if eye protection is not worn during treatmentAlternatives to NBUVB (for psoriasis) Patients with moderate to severe psoriasis who have failed topical therapy have other optionsincluding other types of light therapy (e.g. PUVA) as well as immune modifying therapies such asmethotrexate, Enbrel, Humira, and Ustekinumab. The advantage of NBUVB therapy over theseother therapies is that for most patients it has a better safety profile.Who should NOT undergo NBUVB phototherapy: Patients with a history of photosensitivity, lupus, porphyria, or other light sensitive disorders risksevere health complications with NBUVB. Tell your doctor if you might have one of theseconditions.Things you should know before your treatment: NBUVB is not a cure. It usually takes about 30-35 treatments to get many skin conditions undercontrol, rarely fewer and often more. Once control is achieved, you will still need to come in forregular light treatments at fixed intervals. It will be your responsibility to make sure you have updated valid referrals (with a sufficientnumber of visits) from your primary care physician. Note that without a valid referral, we cannotcontinue treatments. If your referral expires, you will be asked to sign a waiver indicating thatyou know you are responsible for paying the costs of any treatments given without a referral.Our policy is to allow patients a total of 3 treatments beyond the expiration of a referral as a graceperiod while the next referral is in process.Insurance considerations: Most patients do not have difficulty in getting NBUVB covered by insurance (an exception is Tuftswhich typically does not allow coverage for patients with vitiligo) To be certain that your particular plan covers the treatment, we strongly recommend that you callyour insurance company and verify coverage of the following codes:o For psoriasis patients (Diagnosis code = L40.0; Procedure code = 96910)o For eczema patients (Diagnosis code = L20.9; Procedure code = 96910)o For pruritus (itch) patients (Diagnosis code = L29.8; Procedure code = 96910)o For vitiligo patients (Diagnosis code = L80; Procedure code = 96900)PLEASE SEE REVERSE SIDEJCv2015-10-03Immediately before and during treatment: Do not apply sunscreen, calcipotriene / Dovonex / calcitriol, or LacHydrin on the day of treatmentto areas you wish to treat For full body treatments only: If you are a male, cover your genitals (with underwear--or a sock ifyou are treating the groin area). If you are a female and your treatment includes the breasts,cover nipples with either a Band-Aid or zinc oxide cream. Tell the NBUVB technician if you have any changes in your medications (including over thecounter meds) during the course of your treatments. Some medications can increase toxicity ofthe light leading to burns. Any medication that bears a warning label about easy burning innatural sunlight will cause enhanced burning while receiving artificial light COVER AREAS CONSISTENTLY DURING EACH TREATMENT. IF YOU EXPOSE A NEWAREA THAT HASN’T ACCLIMATED TO THE LIGHT, YOU RISK A POTENTIALLY SERIOUSBURN. Apply a thin film of petrolatum or mineral oil immediately before treatment (except for itch andvitiligo patients)After your treatment: Consistency is very important for effective treatments. If you frequently miss treatments, you canexpect less satisfying results and possibly treatment failure In order to have your skin condition managed optimally, you will need to be seen regularly by thedermatologist who is treating you. If you fail to follow-up with the ordering physician, we will beunable to continue treating you with NBUVB. Given the possibility of an increased rate of skin cancer, you are encouraged to see yourdermatology provider at least once yearly for full skin checks.Before and after treatment, you should avoid additional exposure to sunlight during the course of yourtreatment. Especially on the day of treatment, additional sun exposure could lead to severe sunburn.
My skin type:When I spends time outdoors in the sun NOT wearing sunscreen:

(I) I always burn, never tan 1 to 3min

(II) I usually burn, sometimes tan 2 to 4min

(III) I sometimes burn, usually tan 3 to 5min

(IV) I minimally burn, tan easily 4 to 6min

(V) I rarely burn, tan profusely 6 to 8min

(VI) I never burn 8 to 10min

My signature below means that I have read and understood this entire consent form and knowabout the potential risks including but not limited to dryness, itching, burns, including blisteringones, premature aging of the skin, early cataract formation (if I do not wear my goggles asdirected), and potentially increased risk of skin cancer formation.

Signature