Pulsed Red Light Therapy Consent

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Submission Received

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Revive Body MD

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Patient Intake

Personal Information

Full Legal Name

Date of Birth

You must be 18+ to proceed.

Date of Service

Section 1

Description

Pulsed Red Light Therapy (also referred to as low-level light therapy or photobiomodulation) uses specific wavelengths of red and/or near-infrared light delivered in a pulsed pattern. The light is applied externally to the body or face using a non-invasive device.

Commonly used to support:

Skin health and appearance
Muscle recovery and inflammation support
Circulation and cellular function
General wellness and recovery

This service is considered a wellness / aesthetic modality and is not a medical treatment or cure.

Section 2

Potential Benefits

Potential benefits may include, but are not limited to:

Temporary improvement in skin tone or texture
Reduced muscle or joint discomfort
Enhanced recovery and relaxation
Improved overall sense of well-being

Results are variable and not guaranteed.

Section 3

Risks & Side Effects

Pulsed red light therapy is generally well tolerated. However, possible side effects may include:

Temporary redness or warmth in the treated area
Mild headache or eye sensitivity
Tingling or temporary discomfort
Fatigue or lightheadedness
Rare skin irritation or photosensitivity reaction

I understand that unknown or unforeseen side effects may occur.

Section 4

Contraindications

Medical Confirmation

I confirm that I do not have any of the following unless disclosed below:

Pregnancy or suspected pregnancy
History of seizures or epilepsy triggered by light
Active cancer in the treatment area
Known photosensitivity or light-sensitive conditions
Use of photosensitizing medications (e.g., certain antibiotics, retinoids)

Medical Disclosures (Optional)

I confirm that I do not have any of the listed contraindications unless disclosed above.

Sections 5-6

Terms of Service

I agree to wear protective eyewear as instructed and acknowledge that failure to do so may increase the risk of eye irritation or injury.

I understand that this therapy is not a substitute for medical care, and no specific result or cure has been promised.

Section 7

Consent & Release

I have had the opportunity to ask questions regarding this treatment. I voluntarily consent to receive pulsed red light therapy and release and hold harmless the practice from liability associated with this treatment.

I agree to the terms above.

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Electronic Signature

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