LED Light Therapy Consultation and Waiver Form

  • Client Consultation Form

  • Personal/Medical History Form

    To ensure you receive the most appropriate LED Light Therapy treatment, please complete the following questionnaire. All information provided will remain strictly confidential.

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us*

  • Medical History

  • Are you pregnant or breastfeeding?*
  • Do you have epilepsy or a history of seizures?*
  • Do you have any photosensitive conditions or disorders?*
  • Are you currently taking any photosensitizing medications (e.g., antibiotics, acne meds, chemotherapy)?*
  • Do you have any skin conditions (e.g., eczema, psoriasis, rosacea)?*
  • Do you have a history of skin cancer or precancerous lesions?*
  • Do you have any active infections, wounds, or open sores in the treatment area?*
  • Do you have any autoimmune disorders?*
  • Do you have any heart conditions or pacemakers?*
  • Do you have any allergies to light therapy or photosensitive products?*
  • Do you have any metal implants or tattoos in the treatment area?*
  • Do you currently use Retin-A, Accutane or similar?*
  • Are you currently under the care of a physician for any condition?*
  • Are you currently taking any prescription or over-the-counter medications?*

  • AFTERCARE

    LED LIGHT THERAPY

  • LED LIGHT THERAPY AFTERCARE INSTRUCTIONS
    To ensure optimal results and minimize the risk of irritation or complications, please carefully follow the aftercare instructions below:

    • Avoid direct sun exposure for 24–48 hours post-treatment.
    • Use a broad-spectrum sunscreen daily.
    • Avoid exfoliating products or harsh skincare for 48 hours.
    • Keep the treated area clean and moisturized.
    • Do not apply makeup immediately after treatment if possible.

    Notify your technician immediately if you experience unusual redness, swelling, or discomfort.

     

  • ACKNOWLEDGMENT

    LED LIGHT THERAPY CONSENT FORM AND RELEASE FORM

  • Please read each statement carefully. By checking each box, you confirm that you understand and agree to the statement.

  • I,            am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing, and wish to receive the LED Light Therapy treatment.

  • Date*
     - -
  • Should be Empty: