Health History

Patient Gender*

Patient Name*

First NameLast Name

Patient Birth Date*

MonthDayYear

Age*

Address. *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number *

Area CodePhone Number

Patient Height (ex5.7)*

Patient Weight (in lb)*

Patient E-Mail*

Reason for visit:*

ex: Routine Check-up

Please list if you have any drug allergies*

ex: Penicilin

Have you ever experienced allergic reaction, specifically anaphylaxis?*

Please list your current medications*

Have you ever had (Please check all that apply)*

Are you pregnant or breastfeeding? *

Any surgeries?

Do you smoke or vape?

NoYes

Include other important comments regarding your Medical History, if nothing, type N/A*

I understand insurance is not accepted for services or medications at Revive Infusion & Injection Service/BioRenew Services *

I understand refunds will not be issued for any services at Revive Infusion & Injection Services/BioRenew Services*

I understand my participation in services at Revive Infusion & Injection Services/BioRenew Services is completely voluntary and services are not intended to diagnose, treat, or cure any medical condition.*

Red Light Therapy (RLT) is a non-invasive procedure that utilizes light-emitting diodes (LEDs) to deliver concentrated light to the body, aiding in cellular regeneration and healing. While RLT offers numerous potential benefits, it is essential to understand the associated risks and your responsibilities as a client. Please read the following carefully before signing.

Benefits of Red Light Therapy:

- Improved skin tone and texture

- Reduction of pain and inflammation

- Accelerated wound healing

- Enhanced recovery from chronic illnesses

- Increased circulation and oxygenation of tissues

Potential Risks:

While RLT is generally safe, the following risks may apply:

- Temporary redness or irritation at the treatment site

- Eye discomfort or damage without appropriate protection

- Possible interaction with certain medications (e.g., high blood pressure, thyroid medications)

- Temporary drop in blood sugar levels for Type 2 Diabetes patients

- Risk of Herxheimer reaction (flu-like symptoms) from rapid detoxification

Absolute Contraindications

- ____ Pregnancy

- ____ Active melanoma or other cancers

- ____ Epilepsy or seizure disorder

- ____ Pacemaker or other implanted medical devices

Special Precautions:

- Clients on high blood pressure or thyroid medications will be closely monitored. Thyroid must be covered during the session.

- Clients with Type 2 Diabetes must ensure they consume a snack before or after the session to avoid low blood sugar levels.

- Clients with chronic illnesses (e.g., Lyme disease) will start with shorter exposure times, which will be gradually increased based on tolerance.

- Clients with darker skin tones may require reduced session lengths to prevent overexposure, as determined by the technician.

-Medical history including current medications must be listed on health history. Any or all medications have the potential to become inactive, too potent ,or other unknown pharmacokinetic outcome.

Client Responsibilities:

1. I agree to wear eye protection throughout the session as directed.

2. I will inform the technician of any discomfort during the session and understand that I can use the kill switch located on the right-hand side of the bed if needed.

3. I will not use lotions, oils, perfumes, or jewelry during the session and agree to remove such products with provided wipes if necessary.

4. I understand that a maximum of three sessions per week (7 day period)is recommended to avoid potential side effects from excessive exposure, with 24 hours between sessions.

5. I acknowledge that my session length will be determined by the technician based on my individual needs and medical history.

Consent:

I have read and understood the above information regarding Red Light Therapy. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I voluntarily consent to receive Red Light Therapy treatments provided by BioRenew Services by Revive Infusion & Injection Services. I understand that I may withdraw my consent at any time.

I hereby release BioRenew Services by Revive Infusion & Injection Services, its employees, agents, and affiliates from any liability for injury, loss, or damage that may result from the Red Light Therapy sessions.

By signing below, I acknowledge that I have read and understand the information regarding these wellness services. I am aware of the potential benefits and risks, and I voluntarily consent to receive these therapies. I release Revive Infusion & Injection Services / BioRenew Services and its team from liability for any adverse effects that may arise from my participation in these services.

Do you have any of the absolute contraindications to treatment: Pregnancy, Seizure/Epilepsy/active melanoma or cancer/ Pacemaker or other implanted devices *

I have read the above informed consent*

YesNo

Signature

Health History - must complete

General Information

Medical History