Laser Therapy Waiver

Light Force Laser Therapy

Please complete the form below prior to participating
Laser therapy is a safe, non-invasive, FDA cleared modality for the treatment of pain and the temporary increase of microcirculation. LightForce therapeutic lasers emit infrared light energy into tissue to provide topical heating for the purpose of elevating tissue temperature for temporary relief of minor muscle and joint pain, muscle spasm, pain and stiffness associated with arthritis and promoting relaxation of the muscle tissue and to temporarily increase local blood circulation.

Laser therapy utilizes visible and invisible laser radiation; therefore, appropriate eye protection is required at all times during treatment.

Effects of your treatment wil continue for up to 18 hours. Individuals respond uniquely to treatment. You may see immediate results after the first treatment, or depending on the severity of your condition, you may require several treatments before beginning to feel results.

Increased soreness may occur after your first laser session. This may be due to changes in circulation to the involved tissues and/ or the impact on different sensory nerves. This is a normal phenomena in the healing process.

You are required to complete the Patient Intake Form prior to treatment to ensure that laser therapy is a viable option for you.
Are you a candidate for laser therapy?

Laser therapy is an FDA cleared modality for the treatment of pain and inflammation and the

temporary increase of microcirculation. Laser therapy can provide relief for many acute and

chronic conditions. This form is a tool to help your clinician determine if you are a candidate for

laser therapy. If you answer yes to any of these questions you will need to discuss details of your

condition with your clinician.

Please check YES or NO to the questions below
Do you have a pacemaker or any other implanted device?*

YESNO
Are you pregnant?*

YESNO
Do you have cancer?*

YESNO
Are you taking medication that may increase your sensitivity to light?*

YESNO
Have you had a steroid injection in the last 7 days?*

YESNO
I understand the above and consent to treatmentI understand that failing to complete any part of my treatment program will reduce my chances of success.
Are you 18 years or older?*

YesNo
Parent / Guardian*

First NameLast Name
Patient Full Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Patient Signature*

Clear
Parent / Guardian Signature*

Clear
Notes
Please complete this if there is anything we should know prior to treatment
Should be Empty:

Light Force Laser Therapy