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This consent form is to be filled out prior to undergoing any Lightwave Therapy.

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. 
 

April 24, 2024    

I  consent to and authorize LISA PRIMPS to perform LIGHTWAVE™ treatments on me. 



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.


 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. 

Cancellation Policy:
Please give us a 4 hour notice or you will be charged a $25 no-show fee.

All transactions are final, and The Primping Place does not offer any money-back guarantees. You recognize and agree that you shall not be entitled to a refund for any service, under any circumstances.

April 24, 2024

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Second Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Third Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's History

Before undergoing LIGHTWAVE™ therapy, you must complete this section. 

Light therapy is not for everyone. Specific medications or conditions can cause a person to develop sensitivity to light. The following questions are intended to help determine if light therapy is the best choice of treatment for you.

The purposes of these treatments are for: Select ALL that apply *
Anti-aging
Wrinkles
Pigmentation
Hydration
Post Recovery
Discomfort
Firming
Acne - Blemish Control
Have you ever had any of the following conditions? Please select all that apply.
Acute or Cutaneous Porphyria
Photophobis
Epilepsy and Seizures
Hypomelanism (Albinism)

If you answered yes to any of the above conditions then you are probably not a candidate for light therapy treatments due to the immense amount of pulsing and continuous light being administered. 

Have you ever had any of the following conditions? Select all that apply.*
Skin Cancer
Eye disease/retinal abnormalities
Migraines
Diabetes
None of the above

If you answered yes to any of the above conditions then it is highly recommended you consult with your physician before commencing with light therapy. 

Are you currently pregnant or planning to become pregnant in the next eight weeks?*
No
Yes
Do you have any contagious or infectious conditions?*
No
Yes
Are you currently taking or have you taken any antibiotics in the past 7 days?*
No
Yes
Do you take aspirin products, anti-inflammatory medicines or headache medicines?*
No
Yes

If yes which one(s)? Patients who frequently use anti-inflammatory and aspirin products often require more treatments to achieve desired results.

Please list all 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 2 weeks:*
Facial Peels
Injectables
Microcurrent facial
Microdermabrasion
Oxygen facials
Laser Resurfacing
IPL (Intense Pulse Light)
Pulse Dye
ALA (Aminolevulinic acid)
Laser Hair Removal
Tattoo Removal

Please let us know if you have had something else done that was not listed above.

Please list any cosmetic treatments you have had in the past five years:

Were you satisfied with your results? Why or why not?

What areas or problems concern you the most?
Please carefully 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.
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®)
Haloperidol (Haldol®) -May be associated with photo sesitivity -Prolonged Redness -May not allow treatment to be as effected and may require more sessions
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®)
Griseofulvin (Grifulvin®)
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®, Solodyn®, Dynacin®, Sebomin®)
Oxytetracycline
Demeclocycline
Lymecycline
Methotrexate (MTX®, Aminopterin®, Ledertrexate®
Auranofin (Ridaura®)-If a patient is taking this medication, they are not a candidate for light therapy.

The above drugs are currently the most common medications associated with photosensitivity and are by no means a complete list of all 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 all 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:

Do you currently smoke? If yes, how much and how often?

Have you ever smoked? If yes, how long did you smoke for?

Do you drink alcohol? If yes, 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 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:
Select the choice that best describes your skin.
TYPE I- Highly sensitive, always burns, never tans. Example: Red hair with freckles
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. Example: Darker Caucasians
TYPE IV- Minimal sun sensitivity, occasionally burns, always tans to moderate brown. Example: Mediterranean.
TYPE V- No sun sensitivity, rarely burns, tans well. Example: Asian, Hispanic and Arabic
TYPE VI- No sun sensitivity, never burns and tans with ease, deeply pigmented. Example: Darker Blacks.
Are you allergic to latex?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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