• Client Information & LED Therapy Consent Form

    Client Information & LED Therapy Consent Form

    * Fields are Required
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Rows

  • HEALTH INFORMATION:

  • Have you tried LED Therapy before?*
  • Do you wear contacts or glasses?*
  • Do you currently have any open wounds?*
  • Have you ever been diagnosed with epilepsy?*
  • Do you have diabetes or any other autoimmune diseases?*

  • Health Information (Cont.)

  • Head & Neck:*
  • Skin & Infections:*
  • Respiratory:*
  • Cardiovascular:*
  • Musculoskeletal:*
  • Eye:*
  • Nervous System:*
  • Other Conditions:*
  • Are you currently taking any steroidal medications?*
  • Do you use any medications that cause light sensitivity?*

  • Suitability for LED Light Therapy

    LED Light Therapy harnesses the healing power of light for a total skin rejuvenation solution. By sending soothing energy deep into the tissue, LED works on a cellular level to combat active acne, reduce redness and rosacea, stimulate collagen production, induce faster healing and more. 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.

  • PLEASE CONFIRM THE FOLLOWING:

  • AS A CLIENT, YOU HAVE A RESPONSIBILITY TO INFORM THE TECHNICIAN WORKING ON YOU, OF ALL POSSIBLE CONCERNS. PLEASE READ THE FOLLOWING AND CONFIRM EACH STATEMENT.

  • I have read the above information and have given an accurate account of the questions. If I have any concerns, I will address these with my therapist before the service. I understand that the services offered are not a substitute for medical care and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the therapist in giving better service and is completely confidential.

  • Once you submit this form we will reach out to schedule your appointment. If you already have an appointment, thank you for submitting your contact information and consent form.

  • Reload
  • Should be Empty: