Consent for Red Light Therapy

Consent for Red Light Therapy or PhotoBioModulation Treatment

Name(Required)
Address(Required)

Red Light Therapy is a proven, non-pharmaceutical, non-invasion treatment option for a variety of different conditions.

Are you over 18 years old?(Required)

Do you have any of the following conditions?

Pacemaker.(Required)
Epilepsy and Seizures(Required)
Do you take any photosensitive medications?(Required)
Are you pregnant?(Required)
Do you have any contagious or infectious conditions?(Required)
Hypomelanism (albinism)(Required)

Possible Side Effects

Although there are no known significant side effects from using Red Light Therapy, if during or after your treatment you experience such concerns as uncomfortable heat, prolonged redness of the skin, swelling, itching, or severe headaches, please inform us. These issues could indicate sensitivity to light, in which case discontinuation of treatment would be recommended. Please note that these minor side effects rarely occur, and usually subside within 24 hours of discontinuing the treatment.

side effects(Required)

Pre/Post Treatment Instructions

For a maximum effective treatment, it is important that the treated area be cleaned to remove all moisturizers, lotions, cream and makeup prior to starting any treatment session. Metals, and jewellery should be removed from the area to be treated. I agree to wear the protective eye goggles for the duration of my session and will not look directly at the light source.

pre/post treatment(Required)

CONSENT. I agree to the following

  • Medical conditions that are not conducive to Red Light Therapy include pregnancy, use of a pacemaker, epilepsy, hypomelanism / melanin deficiency, contagious or infections conditions, conditions with photosensitivity like lupus, or if you are on medications that make you photosensitive.
  • Although Red Light Therapy is safe, at this time we are not able to treat anyone who is under the age of 18.
  • I understand the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume these risks. I have carefully read and understand this agreement and fully understand its contents.
  • I release The Space Inc. and its operators from any liability associated with this treatment. I certify that I am a competent adult of at least 18 years of age and sign this at my own free will.
Consent(Required)