Red Light Therapy Client Agreement & Billing Authorization
Please complete this form to acknowledge understanding of risks and rules, select your membership or session package, and authorize billing for Red Light Therapy services.
Client Information
Please provide your personal details below.
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Terms, Risks, and Rules
*
Please acknowledge that you have read and agree to the following terms:
- Red Light Therapy (RLT) is a non-medical wellness service for general wellness, relaxation, and support of overall well-being. It is not intended to diagnose, treat, cure, or prevent any disease or medical condition. No specific results are guaranteed.
- You certify that you have no conditions that contraindicate light exposure, and agree to consult your physician if you have any such conditions. You agree to wear protective eyewear and follow all posted instructions and safety guidelines.
- You voluntarily assume all risks associated with RLT, including temporary warmth, redness, irritation, or rare adverse reactions. You agree to stop use and notify staff if discomfort occurs.
- You release and hold harmless the business, its owners, employees, affiliates, and equipment providers from any and all liability, except in cases of gross negligence or willful misconduct.
- You agree to follow all self-service facility rules, maintain hygiene, and comply with business policies. Abuse, sharing, or unsafe use may result in termination of access without refund.
Session or Membership Selection
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Free 1st Session ($0.00)
Single Session ($49.00)
3 Session Pack ($99.00)
7 Session Pack ($199.00)
10 Session Pack ($249.00)
Monthly Membership ($399/month, recurring)
Exclusive Founder Lifetime Membership (1 session/day, non-transferable, non-refundable) ($1,999.00)
Billing Authorization
*
I am enrolling in Monthly Membership and authorize recurring monthly billing to my card on file.
I am purchasing sessions/packages only; no recurring billing applies.
Client Signature (required)
*
Date Signed
*
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Month
-
Day
Year
Date
Printed Name
*
First Name
Last Name
Staff Initials (for office use)
Submit Agreement
Submit Agreement
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