RED LIGHT THERAPY INFORMED CONSENT, ASSUMPTION OF RISK, RELEASE Gray & Ko. Salon and Spa, LLC | 119 North Main Street, McPherson, Kansas | Customer Form
1. Nature and Purpose of Service Red light therapy, sometimes called photobiomodulation, uses visible red and near-infrared light and is represented by the facility as non-UV light exposure. The service is elective and is offered solely for cosmetic and generalwellness purposes. Gray & Ko. Salon and Spa, LLC (“Facility”) and its personnel do not diagnose disease, prescribe treatment, or provide medical advice through this service. I understand that experiences and results vary; benefits may be temporary or may not occur; and no specific result, cure, diagnosis, or medical outcome has been promised. I will direct medical questions to a licensed healthcare professional.
2. Required Screening and Disclosures Please initial each statement. If a statement is inaccurate, uncertain, or requires explanation, stop and speak with Facility personnel before using the device. I am at least 18 years old and have provided accurate identifying information.
I have reviewed the device instructions presented to me and will follow all posted and verbal safety directions.
I am not using a medication, topical product, supplement, or cosmetic known to cause light sensitivity, or I have obtained advice from a qualified healthcare professional before use.
I do not have a known light-triggered seizure disorder, abnormal photosensitivity, active skin cancer, an undiagnosed suspicious skin lesion, an open or unhealed wound in an exposed area, or another condition for which a healthcare professional has advised avoiding intense light exposure.
I am not pregnant or nursing, or I have consulted a qualified healthcare professional and have been advised whether use is appropriate for me.
I have disclosed any implanted electronic device, recent surgery, active treatment, or significant medical condition that may be relevant, and I understand Facility personnel cannot determine medical suitability.
I will not use the device while impaired by alcohol, drugs, illness, or any condition that prevents me from understanding instructions or exiting safely.
3. Potential Risks and Sensations I understand that foreseeable risks and effects may include temporary warmth, redness, dryness, skin irritation, headache, dizziness, eye strain, visual discomfort, aggravation of light sensitivity, an unexpected reaction with a medication or topical product, anxiety or discomfort in an enclosed space, and slips, falls, or strains while entering or exiting the device. Rare or presently unknown reactions may also occur. I will keep my eyes protected as instructed, will not stare directly at illuminated lamps, and will use Facilityprovided eyewear if Facility personnel or the manufacturer’s instructions require it. I understand that eyes being closed may not substitute for required protective eyewear. I will stop the session and seek assistance immediately if I experience burning, significant pain, marked skin reaction, dizziness, shortness of breath, panic, visual disturbance, or other unexpected symptoms. I understand that continuing despite warning symptoms may increase the risk of injury.
4. Session and Equipment Rules I agree to use only the time, positioning, distance, and frequency authorized by Facility personnel and permitted by the manufacturer’s instructions. I will not tamper with controls, bypass a timer or safety feature, block ventilation, alter lamps, bring unauthorized products into the device, or allow another person into the treatment area during my session. The device’s posted maximum user-weight rating and other manufacturer restrictions apply. I will provide accurate information if Facility personnel asks whether a limitation is relevant. A Facility rule or equipment limit may be changed to match current manufacturer instructions, replacement equipment, safety information, or law.
5. Voluntary Choice; Alternatives Participation is voluntary. I may decline or stop before or during a session. Alternatives include not receiving the service, postponing use, or consulting a licensed healthcare professional. I understand that payment, package, cancellation, and refund terms are governed by Facility’s separately disclosed policies and do not require me to continue an unsafe session.
6. Assumption of Risk I knowingly and voluntarily assume the ordinary and inherent risks of receiving and using red light therapy, including the risks described above and risks arising from my failure to disclose relevant information or follow instructions. I understand that assumption of risk does not excuse Facility from duties that Kansas law does not permit it to disclaim.
7. Release and Covenant Not to Sue To the fullest extent permitted by Kansas law, I release and agree not to sue Gray & Ko. Salon and Spa, LLC and its members, managers, employees, and agents (collectively, the “Released Parties”) for claims for personal injury or property loss arising from the ordinary negligence of a Released Party in connection with my use of red light therapy. This release does not apply to gross negligence, reckless or willful misconduct, fraud, a violation of law that cannot be waived, or any other liability that Kansas law prohibits from being released. It also does not waive claims unrelated to the service or events occurring after I revoke this consent and stop use.
8. Client Responsibilities; Medical Care I certify that the information I provide is accurate and complete to the best of my knowledge. I will update Facility before a later session if my health, medications, products, pregnancy status, or relevant circumstances change. Facility may refuse or stop a session for safety, equipment, legal, or policy reasons. If I experience a serious or persistent reaction, I will seek appropriate medical care. In an apparent emergency, I authorize Facility to contact emergency services, but I remain responsible for resulting charges. Facility personnel are not responsible for monitoring or managing my medical condition.
9. Photo and Marketing Authorization No photograph or testimonial use is authorized by this consent. Any before-and-after photographs, testimonials, or marketing use require a separate, optional written authorization. Refusal will not affect access to the service.
10. Acknowledgment and Consent By signing, I confirm that I have read this document, understand it, had the opportunity to ask questions, and had the opportunity to consult a healthcare professional or attorney. I am not relying on promises outside this document. I voluntarily consent to red light therapy subject to this form and the device instructions.
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