Red Light Therapy Consent Form

"*" indicates required fields

Name*
MM slash DD slash YYYY
Address*

Please read, understand, and check ALL the following

MM slash DD slash YYYY

Are you/do you currently take any of the following

Pregnant/Breastfeeding:*
Low Blood Pressure:*
Epilepsy/Seizures:*
Active Carcinoma:*
Malignant Tissue:*
Haemorrhaging:*
Active Bleeding:*
Infectious Diseases:*
Sensitivity to Light:*
Taking Blood Thinners:*
Taking Nitrates:*
Undergoing Chemotherapy:*

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

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 Mind Body Balance Health & Wellness 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 Mind Body Balance Health & Wellness 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. 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 Mind Body Balance Health & Wellness staff.

MM slash DD slash YYYY

If the Client is Under 18 Years of Age

As Parent/Legal Guardian of the above listed Client, I acknowledge that I have read and understood the safety standards and warnings provided to me by Mind Body Balance Health & Wellness and thereby authorize the consumer named above to use red light/LED light therapy.

I acknowledge that I have read and completely understand this consent form, and agree to the above waivers of liability, recommendations and terms.

I attest that I have provided accurate age, identity and relationship verification.

MM slash DD slash YYYY