New Customers Please Fill Out The Intake Form Below Before Your Scheduled Session.

Client Intake Form

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

State *

City *

Postal code *

Red Light Wellness is a red and near-infrared(NIR) light therapy laydown unit used to treat your entire body in 15 minutes or less. It delivers effective technology that promotes decreased systemic inflammation, addresses injury, reduces pain, and increases blood circulation.

Treatment Contraindications for Red Light Wellness

Most can use red light therapy treatments, but there are some special considerations;

Persons diagnosed with active basal cell carcinoma
Women who are pregnant should consult their physician before beginning red/NIR light therapy treatments.
Clients with Epilepsy should consult their physician before beginning red/NIR light therapy treatments.

Taking medications that cause sensitivity to light (for example: tetracycline)

Cautions with medications because of light sensitivity.

The following medicines are known to cause temporary photosensitivity:

Amiodarone (Anti-Arrythmic), also known as Amiodarone Codarone x, Pacerone. Treatment can be administered at the physician’s discretion.
Anti-Arrhythmic Amiodarone (Pacerone® Cordarone® Aratac®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Chlorpromazine (Chlorpromazine HcL, Sonazine Thorazine®, Chloramead®, Chlordryprom®, Chlor® Promanyl®, Largactil®, Promapar®, Promosol®, Terpium®, Sonazine®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Acne Oral Isotretinoin (Accutane®, Accure®, Aknenormin®, Amnesteem®, Ciscutan®, Claravis®, Isohexal®, Isotroin®, Oratane®, Sotret®, Roaccutane®) The client can be treated if the medication has not been taken within the last 6(six) months.
Topical Isotretinoin (Isotrex®, Isotrexin®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Anti-Psychotic Haloperidol (Haldol®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Trifluoperazine (Stelazine®, Clnazine®, Novoflurazine®, Pentazine®, Solazine®, Terfluzine®, Triflurin®, Tripazine®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Anti-Fungal Griseofulvin (Grifulvin®) Grifulvin V, Fulvicin P/G, Gris-Peg. Client can be treated if the medication has not been taken within the last 5(five) days.
Antibiotics Tetracycline (Helidac®, Terra-Cortril®, Terramycin®, Sumycin®, Actisite®, Bristacycline®, Actisite®, Tetrex®, Doxycycline®, Ciprofloxacin®, Tetracycline HcL, Achromycin V) Client can be treated if the medication has not been taken within the last 5(five) days.
Norfloxacin (Noroxin®, Quinabic®, Janacin®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Ofloxacin (floxin®, Oxaldin®, Tarivid®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Nalidixic acid (NegGam®, Wintomylon®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Ciprofloxacin (Cipro®, Ciproxin®, Ciprobay®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Minocycline (Minomycin®, Minocin®, Arestin®, Akamin®, Aknemin®, Solodyn®, Dynacin®, Sebomin®) Client can be treated if the medicine has not been taken within the last 7(seven) days
Oxytetracycline Client can be treated if the medicine has not been taken within the last 7(seven) days
Demeclocycline Client can be treated if the medicine has not been taken within the last 7(seven) days
Lymecycline Client can be treated if the medicine has not been taken within the last 7(seven) days
Cancer Methotrexate (MTX®, Aminopterin®, Ledertrexate®, Folex, Trexall). Client can be treated if the medicine has not been taken within the last 3(three) days.
Arthritis Auranofin (Ridaura®) Client can be treated if the medicine has not been taken within the last 7(seven) days

Skincare Products & Red Light Wellness

Fresh, clean skin is best for treatments

Products can affect how photobiomodulation treatments penetrate the skin or change the performance on a cellular level.

Preparing Your Skin for Red Light Therapy

Preparing your skin for red light therapy helps you get the most out of your PBMT treatment. Before your appointment:

Perform your skincare routine as usual in the days leading up to your appointment. (minus photosensitive products). On the day of your appointment, do not use any lotions, creams, or serums on any part of the skin. Any product that contains sunscreen will block some of the wavelengths. While manufacturers design sunscreen to block ultraviolet A(UVA) or ultraviolet B (UVB) light, it can also stop the red and near-infrared LED lights used in red light therapy.
Retinol, also known as vitamin A, is a common ingredient in moisturizers, serums, and other anti-aging products. Using retinol before bedtime is a great way to encourage cell growth and replacement while you sleep. Applying retinol after red light therapy can boost your skincare routine. However, you should never apply retinol before a PBMT treatment, as the combination can cause unexpected skin reactions and irritation.
Treat your skin nicely before treatments—avoid irritating your skin with exfoliant products
Clean your skin with a gentle, non-drying cleanser before treatment to remove any mineral-based sunscreen or makeup containing zinc
Remove any KT tape or bandages with adhesive and make sure to remove all sticky residue as it can attract light and cause burning.

Post Treatment Skincare. What you do after your Red Light Wellness session is also important. Red light therapy helps your skin absorb creams and serums, making post-PBMT the right time to apply anti-aging products, moisturizers, and other cosmetic products.

Before applying heavier moisturizers, start with serums and eye creams, which are lightweight and often contain concentrated active ingredients. Apply sunscreen last, even if you do not plan to spend much time outdoors.

Ask your skin care professional for suggestions on the best products after red light therapy. In most cases, you can return to your regular skincare routine immediately after your PBMT session. Your skincare consultant may be able to recommend products to optimize the beneficial effects of red light therapy. Preparing your skin for red light therapy can help you optimize and enhance the results you receive.

By submitting this intake form I consent to having this company perform Red Light Wellness therapy procedure on me. *

I agree

I do not agree

The nature and purpose of the treatment has been explained to me, and any questions I have regarding this treatment have been explained to my satisfaction. *

Clear

I understand that with any treatment, certain risks are involved and that any complications or side effects from unknown causes could occur. I freely assume these risks. *

Clear

I understand that the LED light procedure should not be administered to people with the following conditions and I do not have any of these conditions. (Persons diagnosed with basal cell carcinoma, Pregnancy, Epilepsy, Taking medications that cause sensitivity to light for example tetracycline *

I understand

I do not understand

I am over 18 years of age. *

Yes

I will call to inform my practitioner of any complications or concerns I may have as soon as they may occur. *

Clear

I give permission to my practitioner to perform the red/NIR therapy we have discussed and will hold him/her and his/her staff harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my practitioner will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult my practitioner immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the practitioner, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed. *

Clear

Date Intake Form Was Submitted *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.