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LED Therapy Consent Form 

Do not receive LED Therapy if ANY of the following contraindications apply:

Contraindications:

  • Under the age of 12
  • Pregnant or breastfeeding
  • History of epilepsy or seizures
  • Currently taking photosensitizing medications (certain antibiotics like Tetracycline, Accutane)
  • Diagnosed with photosensitive disorders
  • Active cancerous tumors or metastasis
  • Recent cortisone or steroid injections (within the past few days)
  • Please let us know if you have any other medical conditions that may interact with the LED Therapy.

Consent & Release of Liability:

I understand that:

LED Therapy is a non-medical, non-invasive treatment and does not diagnose, treat, or cure any medical conditions. 

I Agree

No guarantees or warranties have been made regarding results or effectiveness, and individual results may vary. 

I Agree
 

I have been informed of the potential risks, contraindications, and precautions, and I voluntarily elect to proceed with treatment. 

I Agree

I assume all risks associated with this treatment and acknowledge that Sage Wellness Spa LLC has advised me of possible outcomes, including but not limited to skin irritation, increased sensitivity, or an unexpected reaction. 

I Agree
 

I release, discharge, and hold harmless Sage Wellness Spa LLC, its employees, contractors, subsidiaries, and representatives from any and all liability, including but not limited to injuries, adverse reactions, or complications that may arise from this treatment, whether seen or unforeseen. 

I Agree
 

I acknowledge that I have had the opportunity to ask all questions and that all my concerns have been addressed. 

I Agree

Signing below indicates that you have provided accurate and complete medical information, and are aware of the contraindications and confirm that none of them apply to yourself.

[today's date]

First Client's Name
First Name*
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
First Client's Signature*
Second Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Third Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fourth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Fifth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Sixth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Seventh Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Eighth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Ninth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
Tenth Client's Name
First Name*
Last Name*
Client's Date of Birth*
Date of Birth
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*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
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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