Client Health History: Light-Emitting Diode (LED) Therapy

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home/Cell Phone*

Work Phone*

Email*

How should we contact you?*

Home/Cell Phone
Work Phone
Email

When is the best time to contact you?*

Morning
Daytime
Evening

How did you hear of us?*

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Relationship To You*

Health History

List any allergies you have*

Please list all current medications you are taking (including oral and topical prescriptions, over-the-counter herbs, vitamins, and supplements)*

These questions are relevant to your skin health and may be contraindications for .
Please answer thoroughly.

Are you pregnant or nursing?*

Yes
No

Do you wear contacts or glasses?*

Yes
No

Do you have any heart problems?*

Yes
No

Do you currently have any open wounds?*

Yes
No

Have you ever been diagnosed with epilepsy?*

Yes
No

Do you have an autoimmune disorder or connective tissue disease?*

Yes
No

Have you had any previous facial treatments?*

Yes
No

Do you use Retin-A, Accutane, or any other prescribed topical Vitamin A derivative?*

Yes
No

Do you use any medications that cause light sensitivity?*

Yes
No

Any other health condition not listed:

Is there anything else we should know about?

Informed Consent

Although every precaution will be taken to ensure your safety and wellbeing before, during, and after your LED treatment, please be aware of the following information and possible risks. Please initial.

I understand there are certain contraindications that would preclude me from receiving LED treatments, including epilepsy, medications causing light sensitivity, open wounds, pregnancy, and thyroid conditions.*

I understand there are other precautions that should be considered before receiving LED therapy treatments and may require a doctor's release and/or I assume any risk involved.*

I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations.*

I understand that some clients report slight tingling sensations and flashing of the optic nerve during the procedure.*

I understand that while the goal of this treatment is to improve the viability of the skin, no specific guarantees of the result can or have been made.*

I understand that it is imperative to my health that I disclose all of the information requested in the Client Profile/Health History.*

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.*

I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.*

I consent to "before and after" photographs for the purpose of documentation, potential advertising and promotional purposes.*

I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the LED procedure we have discusses, and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that i Have had sufficient opportunity for discussion to have my questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Client Name*

First Last

Date*

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