Items to consider before LIGHTWAVE™ Therapy:
1. It is important to tell staff if you are pregnant, diabetic, taking antibiotics, or have cancer.
2. The final results may not be apparent for several weeks after the treatments.
3. Sun bathing, alcohol consumption, smoking and eating habits directly affect outcome of the treatment. Remember to eat well and limit sun bathing, alcohol and smoking to a minimum.
4. Drink at least 8oz of water before and after the treatment.
5. Do not apply creams, moisturizers or antiperspirants before a treatment.
6. It is important to notify the clinic if there are any problems or concerns after the treatment, including prolonged redness.
7. The fee is paid for the treatment itself. There is no guarantee that the expected or anticipated results will be achieved.
8. More than one treatment package may be required. There will be a charge for each additional treatment.
My signature verifies that I have read and understand the goals, limitations, risks, and possible side-effects to the treatment, and that I have been given the opportunity to ask questions. My signature also verifies my informed decision to proceed with LIGHTWAVE™ Therapy and have the treatment. I additionally, consent to the taking of photographs during the course of my LIGHTWAVE™ Therapy for the purpose of medical education.
December 4, 2020
I consent to and authorize LISA PRIMPS to perform LIGHTWAVE™ treatments on me.
I release LTW International 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 will. This consent and waiver form is voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successor, and assigns.
LIGHTWAVE™ Therapy is a non-ablative 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 cellular level. By stimulating the body’s tissues to convert light energy into cellular energy (ATP), a LIGHTWAVE™ treatment provides energy that your cells can use to: • accelerate the production of collagen and elastin • increase cellular permeability, allowing for increased cellular nutrient intake • increase the removal of excess fluid and waste products from the cells • increase the production of macrophage (scavenger) cells for the removal of toxins and scar tissue • increase lymphatic drainage • 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, swelling, itching or severe headaches during or after the treatment. These are all 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 will 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 will vary from person to person and no guarantees can be made that expected or anticipated
Patient Profile & Release P. 6 / 6 Proprietary and Confidential Last Revised: 0211 V.05
results will be achieved. I am aware that follow-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 all 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.
Photographs: 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 will be protected.
The nature and purpose of the treatment has been explained to me. I have carefully read and understand this agreement and fully understand its contents. All 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 LTW International L.L.C, and the undersigned.
Please give us a 4 hour notice or you will be charged a $25 no-show fee.
December 4, 2020