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Light Therapy Waiver & Informed Consent – template

Light Therapy Waiver & Informed Consent

I understand that attending demonstrators are not licensed physicians and are unable to cure, diagnose, mitigate, prevent, or treat conditions. Services provided by the demonstrator are for pain reduction and increased circulation. Light therapy should not be used as a replacement for medical treatment from a licensed physician or other healthcare provider.

I have been informed that light therapy is generally safe. While side effects are not common, if they do occur, they’re usually mild and short lasting. They may include: Increased sensation, itching, or pain to the treated area due to increased circulation, elevated temperature, skin irritation or uncomfortable warmth on the treated area due to increased circulation, eyestrain / headache.

LED light therapy is the process in which certain colors of light are used to trigger naturally occurring physiological processes in the body, including cellular healing and nitric oxide release. Clinical studies show nitric oxide can help increase and support basic functions in nearly every part of the body including, but not limited to, increased circulation, stimulated collagen production, increased lymphatic system activity, and decreased nervous excitability. LED light therapy is non-invasive, non-abrasive, and safe for all ages.

For the diagnosis and treatment of any disease, consult a licensed Physician.

No client information will be disclosed to anyone outside of the demonstration without written consent from the client, unless required by law.

This agreement is made upon the express condition that the demonstrator and device manufacturer shall be free from all liabilities and claims for damages and/or suits for or by reason of any injury, or death to any person or property of the client while in or upon said premises of services given or any part thereof during sessions of this agreement in connection herewith, and the client hereby agrees to hold harmless the demonstrator and device manufacturer from all liabilities, charges, expenses and costs on account of or by reason of any such injuries, deaths, liabilities, claims, suits, damages, or losses however occurring out of each session.

By signing below, I agree that information I have provided is accurate to the best of my knowledge. I have read and understand all above information, and give my full consent to receive light therapy from the demonstrator. I acknowledge that this consent is given of my own free will and conscience, with no outside sources affecting my decisions, and that any questions have been answered by the demonstrator.

Light Therapy Session Waiver - Human

    *If you answered yes to any item, you must get approval from a licensed physician prior to demonstration or use of the device.

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