Red Light Therapy - Health Screening and Consent Form Name First Name Last Name Email Phone (###) ### #### Are you pregnant or breastfeeding? * Yes No Do you have a history of skin cancer? * Yes No Do you have any condition causing light sensitivity (e.g. lupus)? * Yes No Are you currently on any medications that increase light sensitivity (e.g. Accutane, antibiotics)? * Yes No Do you have any active skin conditions or open wounds? * Yes No Have you used a tanning bed or had sunburn in the last 7 days? * Yes No If Yes to any of the above, please provide further details: I understand the nature of Red Light Therapy and its potential risks. * Confirm I confirm that I have disclosed all relevant health information. * Confirm I accept responsibility for my participation and release Revive Health Group from liability. * Confirm I agree to wear protective goggles during treatment. * Confirm I consent to undergo Red Light Therapy. * Confirm Date MM DD YYYY Thank you!
