RED LIGHT therapy Consent Form

CONSENT AND DISCLAIMER

Please fill out the following form
in order to participate in our activity.

First name

Last name

Date of Birth

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Do you suffer from Photosensitizing medical conditions, such as lupus

Yes

Do you take any of the following medication tetracycline, doxycycline, hydrochlorothiazide, naproxen

Yes

If you ticked any of the above items have you consult your Dr undergoing red light therapy. if no please do

Yes

I hereby confirm I have read and understand the risks associated with the Infrared Light treatment and accept all liability for issues that arise following my treatment. I also confirm all information provided is accurate and up to date.

SIGN / Type your name below

Thanks for submitting!

RED LIGHT therapy Consent Form

CONSENT AND DISCLAIMER

Location

Be the first to know!