LED Light Therapy Consent Form
Please review and complete this form to provide your consent for LED light therapy treatment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you previously received LED light therapy?
*
Yes
No
Do you have any of the following conditions? (Select all that apply)
*
Photosensitivity
Epilepsy or seizure disorders
Active skin infections or open wounds
Currently taking medications that cause light sensitivity
None of the above
Other
Please list any medications you are currently taking (if any):
Please provide any additional information about your health or skin that may be relevant to this treatment:
Signature (Required for Consent)
*
Submit Consent
Submit Consent
Should be Empty: