RED LIGHT BED/LED FACIAL LIGHT AGREEMENT AND CONSENT FORM CLIENT INFORMATION

Name & Surname:

Date of Birth:

Phone Number:

Email:

Address:

Please read, understand, and check ALL the following

Always wear protective eyewear. Failure to wear protective eyewear may result in burns or long-term injury to the eyes.

You should prepare your skin for your session prior to your arrival. For optimal results, skin should be free of deodorant, make up, fragrances, oils, and lotions. Remove jewellery.

Certain Medications or cosmetics may increase your sensitivity to the red and/or LED light.

If you are pregnant or nursing we suggest consulting your physician before using LED light therapy.

For optimal results recommended therapy schedules are 3-4 days per week, for 4- 6 weeks. After the initial treatment schedule it is recommended to continue 1-2 days per week.

After treatments sit up slowly to prevent dizziness.

I understand that LED light therapy is not intended to take place of medical care or medications.

To my knowledge, I have no medical condition which would prohibit me from using LED light therapy.

I acknowledge that the results of LED light therapy do vary, and that no guarantees of specific results are offered or implied.

Epitome Face Body and Electrology will not refund or credit any amount of money because of a client’s unhappiness with their final results.

I have been given adequate instructions for the proper use of the equipment, understand the risks involved, and use it at my own risk.

I hereby agree to release the owners, operators and manufacturers from any damages that I might incur due to the use of this facility.

I have reviewed and completely understand all of the information at www.epitomefacebodyandelectrology.com.au, including this form.

Date:

Your Signature

Are you/do you currently take any of the following

Pregnant/Breastfeeding:

Yes

No

Low Blood Pressure:

Yes

No

Epilepsy/Seizures:

Yes

No

Active Carcinoma:

Yes

No

Malignant Tissue:

Yes

No

Haemorrhaging:

Yes

No

Active Bleeding:

Yes

No

Infectious Diseases:

Yes

No

Sensitivity to Light:

Yes

No

Taking Blood Thinners:

Yes

No

Taking Nitrates:

Yes

No

Undergoing Chemotherapy:

Yes

No

Additional Information:

*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 Epitome Face Body and Electrology 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 Epitome Face Body and Electrology 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 from the staff. 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 Epitome Face Body and Electrology staff.

Date:

Client Signature

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 Epitome Face Body and Electrology and thereby authorise 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.

Date:

Parent/Guardian Signature

Your content has been submitted

PH: 0418 951 794

RED LIGHT BED/LED FACIAL LIGHT AGREEMENT AND CONSENT FORM CLIENT INFORMATION

Please read, understand, and check ALL the following

EPITOME

Navigation

Forms