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:
Other: _________________________________ 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. Anti-Arrhythmic Amiodarone (Pacerone® Cordarone® Aratac®)
Chlorpromazine (Thorazine®, Chloramead®, Chlordryprom®, Chlor®
Promanyl®, Largactil®, Promapar®, Promosol®, Terpium®, Sonazine®) Oral Isotretinoin (Accutane®, Accure®, Aknenormin®, Amnesteem®,
Ciscutan®, Claravis®, Isohexal®, Isotroin®, Oratane®, Sotret®, Roaccutane®) Topical Isotretinoin (Isotrex®, Isotrexin®)
Anti-Psychotic Haloperidol (Haldol®)
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®,
Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Anti-Fungal Griseofulvin (Grifulvin®)

Antibiotics Tetracycline (Helidac®, Terra-Cortril®, Terramycin®, Sumycin®, Actisite®,
Bristacycline®, Actisite®, Tetrex®, Doxycycline®, Ciprofloxacin®) Norfloxacin (Noroxin®, Quinabic®, Janacin®)
Ofloxacin (floxin®, Oxaldin®, Tarivid®)
Nalidixic acid (NegGam®, Wintomylon®)
Ciprofloxacin (Cipro®, Ciproxin®, Ciprobay®)
Minocycline (Minomycin®, Minocin®, Arestin®, Akamin®, Aknemin®,

Cancer Methotrexate
(MTX®, Aminopterin®, Ledertrexate®)

Arthritis Auranofin (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: Eyes ____________________________________________________ Face and Neck ____________________________________________ Body ____________________________________________________ Do you currently use professional skincare products? ____________________ If yes, please specify which products for which area: Eyes ____________________________________________________ Face and Neck ____________________________________________ Other: ___________________________________________________ Circle the choice that best describes your skin. TYPE I- Highly sensitive, always burns, never tans.
TYPE II- Very sun sensitive skin, burns easily, tans with difficulty.
Example: Fair skinned, fair haired Caucasians TYPE III- Sun sensitive skin, sometimes burns, slowly tans to light brown.
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown.
TYPE V- No sun sensitivity, rarely burns, tans wel .
Example: Asian, Hispanic and Arabic TYPE VI- 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: __________________________

Source: https://hiddendoorspa.com/wp-content/uploads/2011/03/LightwaveTherapy.Consent.REV012011.pdf


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