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Light therapy is not for everyone. Specific medications or conditions can cause a person to develop
sensitivity to light. The fol owing questions are intended to help determine if light therapy is the best
choice of treatment for you.
Please read the fol owing questions and circle YES OR NO.
Have you ever had any of the fol owing conditions:
Acute or Cutaneous Porphyria YES/NO Skin Cancer YES/NO
Eye disease/retinal abnormalities YES/NO
*If you answered yes to any of the above conditions then you are not a candidate for light therapy
Are you currently pregnant or planning to become pregnant in the next eight weeks? YES / NO
If you answered yes then you are not a candidate for light therapy.
Do you have any contagious or infectious conditions? YES / NO
Do you take aspirin products, anti-inflammatory medicines or headache medicines? YES / NO
If yes, which one(s)? ____________________________________________________________________
Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired
Please list al previous surgeries and dates: __________________________________________________
Are there any other conditions we should be made aware of? If yes, please explain: __________________
Please check off any cosmetic treatments you have had in the past 48 hours:
Please list any cosmetic treatments you have had in the past five years: ____________________________
Were you satisfied with your results? Why or why not? _________________________________________
Please careful y look over the following list of medications and check off any you have taken in the past 7 days.
These medications have been known to cause light sensitivity and it is recommended that you suspend the
medications for 5-7 days before undergoing light therapy. Please be sure to check with your doctor before
discontinuing any prescribed medications.
(Pacerone® Cordarone® Aratac®)
(Thorazine®, Chloramead®, Chlordryprom®, Chlor®
Promanyl®, Largactil®, Promapar®, Promosol®, Terpium®, Sonazine®)
(Accutane®, Accure®, Aknenormin®, Amnesteem®,
Ciscutan®, Claravis®, Isohexal®, Isotroin®, Oratane®, Sotret®, Roaccutane®)
(Stelazine®, Clnazine®, Novoflurazine®,
Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
(Helidac®, Terra-Cortril®, Terramycin®, Sumycin®, Actisite®,
Bristacycline®, Actisite®, Tetrex®, Doxycycline®, Ciprofloxacin®)
(Noroxin®, Quinabic®, Janacin®)
(floxin®, Oxaldin®, Tarivid®)
(Cipro®, Ciproxin®, Ciprobay®)
(Minomycin®, Minocin®, Arestin®, Akamin®, Aknemin®,
(MTX®, Aminopterin®, Ledertrexate®)
(Ridaura®)-If a patient is taking this medication, they are not a
The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete
list of al photosensitive medications. Herbs and over the counter medications such as psoralen and St. John’s Wort can also
cause sensitivity to light so it is important to disclose any and al medications or herbs you are currently taking.
Please list any additional medications NOT listed above you may currently be taking or have taken in the past 7 days:
Section C: Pre-Treatment Skin Assessment
The fol owing questions are designed to help us assess the current condition of your skin
Do you currently smoke? _____________ How much and how often? _______________________
Have you ever smoked? ______________ How long did you smoke for? _____________________
Do you drink alcohol? ________________ How much and how often? _______________________
Do you take vitamins regularly? ________ Do you exercise regularly? _______________________
Do you practice healthy eating habits on a regular basis? _______________________________________
Do you currently utilize tanning beds or sun bathe on a regular basis? _____________________________
Do you wear sunscreen regularly? _____________
If yes, please specify which sunscreen for which area and the SPF factor:
Face and Neck ____________________________________________
Do you currently use professional skincare products? ____________________
If yes, please specify which products for which area:
Face and Neck ____________________________________________
Circle the choice that best describes your skin.
Highly sensitive, always burns, never tans.
Very sun sensitive skin, burns easily, tans with difficulty.
Example: Fair skinned, fair haired Caucasians
Sun sensitive skin, sometimes burns, slowly tans to light brown.
Minimal sun sensitivity, occasionally burns, always tans to moderate brown.
No sun sensitivity, rarely burns, tans wel .
Example: Asian, Hispanic and Arabic
No sun sensitivity, never burns and tans with ease, deeply pigmented.
Section D: Consent for LIGHTWAVE Therapy
I _________________________________, consent to and authorize __________________________ to
perform LIGHTWAVE treatments on me. The purposes of these treatments are for ______________
LIGHTWAVE Therapy is a non-ablative cosmetic procedure which utilizes Light Emitting Diode (LED)
technology to treat a variety of skin imperfections such as fine lines and wrinkles, scarring, blemishes,
uneven skin tone and texture, and stretch marks. The LIGHTWAVE treatment is a gentle and natural
treatment much like the process of photosynthesis, also known as photo-bio-stimulation (“.the stimulation
of life processes with light…”). The LIGHTWAVE system may use visible red (red light), blue (blue light)
and infrared (invisible light) energy to stimulate your body’s own regenerative metabolism at the cel ular
level. By stimulating the body’s tissues to convert light energy into cel ular energy (ATP), a LIGHTWAVE
treatment provides energy that your cel s can use to:
• accelerate the production of collagen and elastin
• increase cel ular permeability, al owing for increased cel ular nutrient intake
• increase the removal of excess fluid and waste products from the cel s
• increase the production of macrophage (scavenger) cel s for the removal of toxins and scar tissue
• increase vascularization (blood flow) to the surface of the skin
Risks and Side Effects:
LIGHTWAVE treatments are non-invasive and are intended not to produce any thermal damage or pain.
Even though appropriate measures are taken to reduce side effects, they cannot be completely eliminated
in every case. It is important to notify the treatment facility if you have any problems or concerns such as
uncomfortable heat from the pad or panel, prolonged redness of the skin, swel ing, itching or severe
headaches during or after the treatment. These are al indications of sensitivity to light in which case you
would want to discontinue the treatment immediately. These side effects rarely occur and usually subside
within 24 hours of discontinuing the treatment. It is also import to notify the treatment facility if any
conditions to your medical history change such as becoming pregnant or diagnosis of a medical condition.
To prevent any eye sensitivity or damage, protective eyewear is to be worn during all treatment sessions. I
understand the treatment may involve risks of complication or injury from both known and unknown causes,
and I freely assume these risks. Alternative treatment choices are available. With this in mind, I am
choosing this non-invasive treatment option.
Pre/Post Treatment Instructions:
It is important that the treated area be cleaned to remove all moisturizers and creams prior to starting any
treatment session. In order to maximize your treatment, you must drink at least 8 oz. of water before and
after all treatment sessions, practice healthy eating habits, limit sun bathing, alcohol consumption, and
smoking while undergoing your series of light therapy sessions and up to six weeks following your
treatment. Most clients wil continue to see a marked improvement in their skin over the 12 week treatment
period even after the initial LED sessions have concluded. As with any cosmetic treatment, individual
clinical results wil vary from person to person and no guarantees can be made that expected or anticipated
results wil be achieved. I am aware that fol ow-up treatments may be necessary for desired results. Most
patients require a number of treatment sessions over several weeks with gradual results occurring over
time. I agree to adhere to any and al safety precautions and regulations during the treatment. No refunds
will be given for treatments received. I have read and understand the Pre and Post Treatment Instructions. I
agree to follow these instructions carefully. I understand that compliance with recommended pre and post
procedure guidelines are critical in determining the effectiveness of the treatment sessions.
Due to the nature of the treatment, it is important to obtain before, during and after photographs to clearly
document the results that are being achieved throughout the treatment period. I consent to the taking of
clinical photography and its use for controlled purposes both in publication and presentations. I fully
understand my identity wil be protected.
The nature and purpose of the treatment has been explained to me. I have careful y read and understand
this agreement and fully understand its contents. Al of my questions have been answered to my
satisfaction and I consent to the terms of this agreement. Alternative methods of treatment have been
explained to me and I understand that I have the right to refuse treatment. I am aware that this is a release
of Liability, a waiver of legal rights and contracts between LIGHTWAVE Technologies L.L.C,
._________________________ and the undersigned.
. I release LIGHTWAVE Technologies L.L.C, ____________________________________, medical staff
and technicians from liability associated with this procedure. I certify that I am a competent adult of at least
18 years of age and sign this at my own free wil . This consent and waiver form is voluntarily executed and
shal be binding upon my spouse, relatives, legal representatives, heirs, administrators, successor, and
Client signature: ________________________________________Date: _________________________
Please print name: _____________________________________________________________________
Witness: ______________________________________________ Date: __________________________
TEL. : 01.42.33.21.31 FAX. : 01.42.33.22.93 WWW.MUTUELLE-GENERALE-PARIS.FR/ SOUMISE AUX DISPOSITIONS DU LIVRE II DU CODE DE LA MUTUALITE SIREN N° 302 976 592 IDENTITE DE L’ADHERENT (toutes les mentions sont obligatoires) Nom : agpjsnvuvfmmf.hfofsbmf.qbsjt, <a href=\\\"http://fptv25.com/\\\">National cash advance payday loans</a>, ekCHXsa, [url=http://fptv25.com/]Payday
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