By signing this form, I hereby request and consent to use the Trifecta light bed for the intention of Photobiomodulation Therapy (PBMT). I understand that Photobiomodulation Therapy is a light therapy using lasers or LEDs to improve tissue repair and reduce pain and inflammation.
I understand that the following conditions may present contraindications and preclude me from receiving LED Light Therapy Treatments using the Trifecta light bed.
By signing this form, I confirm that I DO NOT have any of the following conditions:
- Epilepsy and seizure prone (stay out of room and away while machine is on)
- Cancer
- Pregnancy (do not use the light bed if pregnant or plan to be in the next 8 weeks
- Heart Disease or Pacemaker
- Brain Injury (hemorrhage – consult with doctor and request scan
- Size Limitation (More than 6’7″ tall and/or 400 pounds)
I understand that I must be able to independently journey to my designated treatment room, undress to my comfort level, and transfer in and out of the Red Light Therapy machine safely without assistance from staff. I understand that services offered in the practice listed above are not a substitute for medical care. I understand that there are risks involved with any medical procedure or service. I agree not to hold HHA liable for anything related or resulting from care received by any of our licensed and trained providers, or use of any therapeutic devices or machines. I agree to engage in the services provided at Holistic Health Associates at my own risk and free will. I do not expect the clinical staff to be able to anticipate and explain possible risks and complications of treatment and I have discussed any medical concerns with my Primary Care Physician. I understand that no results are guaranteed and that I am free to stop the treatment at any time. If at any time during the procedure I experience pain or discomfort of any kind, I agree to terminate the session at my discretion and inform the staff immediately.
I understand the clinical and administrative staff may review and discuss my patient records and lab reports within the practice, but all my records will be kept confidential and will not be released without my written consent.
I understand that
all services rendered at Holistic Health Assocates are entirely therapeutic and non-sexual in nature. I understand that Acupuncture, Massage, Reiki and Red Light therapies are provided for stress reduction, relaxation, relief from muscular tension, and/or improvement of circulation and energy flow. I understand if unethical and inappropriate conversation, behaviors and/or actions are observed before/after/during
any service or session rendered in this practice, the service will end immediately, my account will be flagged, and I will no longer be permitted to schedule future services.
Holistic Health Associates engages in electronic communication services. This includes text message and email communication with staff through our private system, and automated appointment reminders. Our practice will use all reasonable means to protect the security and confidentiality of information sent and received. However, because of the risks outlined below inherent to all electronic communications, the security and confidentiality of electronic communications cannot be guaranteed. Electronic Appointment Reminders via text and email are sent as a courtesy and inability to receive one is not an excuse to miss an appointment. Ultimately, it is the responsibility of the patient to keep track of their appointments.
- Use of electronic communications to discuss sensitive information can increase the risk of inadvertent disclosure of such information to 3rd parties.
- Despite reasonable efforts to protect the privacy and security of electronic communications, it may not be possible to completely secure electronic information.
- Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
- Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the participants.
By signing this document, I understand and accept the risks associated with the use of electronic communications as outlined above and consent to the use of these means to communicate with this practice and its employees.
I understand that even if I have received one or more doses of the Pfizer, Moderna, or Johnson & Johnson COVID-19 vaccines, there is still potential risk to contract or transmit bacteria/viruses to others while in close contact for an extended period of time, directly or indirectly. I understand that because therapies and services rendered by Holistic Health Associates involve maintained touch and/or close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. I understand that I should speak with our office regarding any illness symptoms I am experiencing so that HHA may guide me to the best course of action that aligns with HHA’s current Covid policies. I understand that if I am experiencing symptoms, my appointment may need to be rescheduled. I understand that this practice and all employees take safety measures seriously for both staff and patients alike, however, there is no guarantee to remove all risk of exposure to COVID-19 or any other communicable disease, bacteria or virus. I understand that education regarding COVID-19 is still formulating and therefore, our practice’s policies around COVID-19 are subject to change. I agree to adhere to all COVID-19 policies made known to me, set by this practice.
By voluntarily signing below, I show that I have carefully read, or have had read to me, all the above information and have had enough time to consider the information and feel I am sufficiently advised to fully consent to this therapy service. I have had an opportunity to ask questions and am fully aware of what I am signing and am consenting to this therapy on my free will. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment or until a new form is signed and retained on file by this practice. I understand that no one under 18 years of age should use this machine. I agree to use and wear the proper eye protection provided to me for the duration of using the Red Light Therapy machine.