lightkeeperchiro.com - Consent Form

Name*

First NameLast Name

Email*

example@example.com

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Congratulations on taking the first step towards reaching your weight loss and aesthetic goals. Today you will be qualified based on several factors including medical history and your level of commitment to achieving your desired results. During today's consultation we will evaluate your areas of concern and see if you qualify for one of our treatment programs. Your success relies on your dedication and compliance with your care plan.

Purpose for Baseline Test-Demo Session

Perform baseline test to determine your body's response and absorption to laser light energy.
Demonstrate effectiveness of our technology. Treatment protocols are individualized and specific. Your program will be determined after the baseline test to assure maximum results.

Demo Session Qualifications:
**Serious Candidates only
**Must be at least 18 years of age or older.

If I qualify for a program: (check appropriate box)

I would like to start a program todayAfter qualification, demonstration and all my questions have been answered I am walling to move forward with treatment options that meet my needs and budgetI am not interested in starting a program

I consent to receiving a health screening. I realize that I am not receiving a diagnosis, treatment or prognosis for any medical or other condition that I may be experiencing. I acknowledge that I am receiving a demonstration only and agree to hold harmless the facility, owners, employees and any subsidiaries from any damage resulting from this demonstration. I understand and accept that visual documentation (photo and/or video) is necessary for evaluation, program monitoring and marketing. I hereby release and hold harmless this clinic and invisa-REDTM technology from any reasonable expectation of privacy or confidentiality associated with the images and/or videos specified above. I further acknowledge that my participation is voluntary and that I will not receive compensation of any type.

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