Red Light Therapy

Client Information

Red Light Therapy
Full Name*
Date of Birth*

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Date
Phone Number*
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Email*
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Emergency Contact Name
Emergency Contact Phone
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Red Light Therapy Consent
Red light therapy is a non-invasive, wellness-based modality using low-level red and near-infrared wavelengths of light to support muscle recovery, reduce inflammation, and enhance overall wellness. It is not a medical procedure and does not diagnose, treat, or cure any condition.
I understand and agree to the following:*

Red light therapy does not diagnose or treat any medical condition.I must wear eye protection during all sessions.Certain medications may increase light sensitivity.I must report any discomfort during the session.I may stop the session at any time.I agree to follow all provider instructions.
Please confirm:*

I confirm I am not taking photosensitive medications OR I have medical clearance.I need to speak with the provider before beginning sessions.

Liability Waiver & Release
Assupmtion of Risk

I understand that participation in red light therapy sessions may involve certain risks, including temporary skin redness, sensitivity, discomfort, or adverse reactions depending on my health status or medications. I voluntarily assume full responsibility for any risks or outcomes associated with my participation.
Initials*
Health Disclosure – Please confirm:*

I have disclosed all relevant medical conditions.I understand that certain medications or conditions may require physician approval.I will notify the provider of any changes in my health status.
Release of Liability

I release, waive, discharge, and hold harmless Hustle, Glam & Grit Red Light Therapy, its owner, employees, and contractors from any and all liability, claims, or actions arising from my participation in red light therapy services, whether caused by negligence or otherwise.
Initials*
May we use before/after photos for marketing? (Optional)

Yes, I consent.No, I do not consent.
Membership Option
Would you like to join our Unlimited Monthly Membership?*

Yes! I want all the Red Light I can get! ($150/month)No, but I would like a 5 session punchcard for $100No, I prefer single sessions. ($25/session)
Agreement and Signature

By signing below, I confirm that the information I have provided is accurate and complete. I acknowledge that I have read, understood, and agree to the Red Light Therapy Consent, Liability Waiver, and all policies presented in this form.
Signature*
Date*

MonthDayYear
Date
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Client Information

Medical History

Red Light Therapy Consent

Liability Waiver & Release

Membership Option