LED Light Therapy Consultation and Consent Form | Aesthetics Forms Portal

LED Light Therapy Consultation/Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do any of the following apply to you? Please tick all that apply.

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

What are your skin concerns? *

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin? *

Which skin care products do you use? *

Do you regularly use SPF? *

Have you received any other aesthetic treatments in the last 6 weeks? *

Please specify (including dates if possible): *

Do you use sunbeds or are regularly exposed to sun? *

What are your goals and expectations of the treatment? *

Treatment Information

What is Light Therapy?

To put it simply, light therapy uses varying color wavelengths of visible LED (light emitting diode) light to provide specific benefits to your skin. Your skin uses this light as a source of light energy to aid in the killing of bacteria. As the light triggers these natural responses in your body it can help promote improvements in the skin as a result of sun damage, acne, rosacea, eczema, psoriasis, dermatitis, sensitive and inflammatory conditions, wound healing and scarring to restore the skin’s radiance.

Types of Light Therapy

The benefits of light therapy are actually tied to the color of light used on your skin. As each color of light has different wavelengths, they affect the skin differently and provide varying results.

Blue Light - Known for its powerful antibacterial properties, blue light is the treatment for acne. The light effectively treats active breakouts without irritation while reducing oil production and helping prevent future acne. Blue light is also a UV-free alternative for the treatment of eczema and psoriasis as it reduces itch and calms inflammation.

Red Light - Most often used for its anti-aging effects as it is especially effective in helping to combat wrinkles, fine lines, sun spots, discoloration, and other visible signs of maturing skin. Specifically, the low wavelengths of red light can help to increase natural hydration levels, reduce redness and inflammation, regulate oil production, and even improve circulation.

Near Infra-Red Light - Very similar to red light, near infra-red light is the most deeply absorbed wavelength, this treatment helps smooth lines and wrinkles, improve skin resiliency, reduce pain and inflammation, and accelerate the wound healing process, including cystic acne. This type of light simply works at a deeper level than red light alone which fights the signs of aging that occur closer to the skin’s surface.

Treatment Frequency

Each LED light therapy treatment lasts around 20 minutes. You’ll likely need up to 10 treatments in total, depending on the results you’re looking to achieve.

Potential Side Effects and Risks

LED light therapy is a safe, relatively risk-free treatment.

It’s rare to experience side effects from LED light therapy. If side effects do occur, they may include:

Increased inflammation
Rash
Redness
Pain

If you have any concerns following your treatment please contact your practitioner.

Aftercare

LED light therapy is noninvasive, so no recovery time is required. You should be able to continue with your everyday activities once your treatment is over.

You may start to see minor results after your first session. Results will be more dramatic and noticeable once you’ve finished all of your treatments.

Even after you’ve achieved the recommended number of sessions, your results aren’t permanent.

Aftercare Advice:

Always wear a broad spectrum UVA & UVB sunscreen
Don’t clean your skin in the evening after your treatment
Allow the serums to soak in and work overnight
Gently cleanse your skin using a mild cleanser for 48 hours post-treatment
Avoid sunbeds and tanning in direct sunlight
Avoid saunas, steam rooms and swimming pools for 24 hours post-treatment

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive LED Light Therapy treatment.

Client Signature: *

Tap or click on the signature above to sign