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Complete this form if:
You are a member and you have added on the red light therapy membership.
You are a radiant wellness member.
You are not a member and you have purchased a single or multipack of radiant healing sessions.
Acknowledgment of Risks And Waiver of Liability
Health problems that are contraindicated for Red Light Therapy :
Malignant Cancers
Eye Diseases
Recent Burns
Light Sensitivity
Hyperthyroidism
Fever/Infection
Epilepsy
Systemic Lupus Erythematosus (SLE)
Pregnancy
Severe Blood Loss/Bleeding
Heart Disease or Pacemaker
Use of Photosensitizing Medications
**If you have any of the above health related problems, you are not a good candidate for red light therapy and will need to be cleared by a medical professional before being able to participate.
Risk Acknowledgment: I understand that using red light therapy may pose health risks, especially for individuals with certain medical conditions. I have informed DW Staff of all relevant health issues and have consulted a healthcare professional when necessary before deciding to use red light therapy. *
Assumption of Risk: I acknowledge and voluntarily assume the risks associated with red light therapy use, understanding that there is a possibility of adverse physical effects, including but not limited to eye damage, skin irritation, and burns.*
Waiver of Liability: I hereby agree to release, waive, discharge, and covenant not to sue the facility, its officers, employees, or agents from any and all liabilities arising from bodily injury, accidents, or death that may occur as a result of my participation in red light therapy activities. This release extends to all claims of every kind or nature, whatsoever, foreseen or unforeseen, known or unknown.*
Emergency Procedures: I agree to immediately report any feelings of discomfort, dizziness, or other concerning symptoms to the staff and cease using the red light if advised by staff or if such symptoms occur. *
Privacy Acknowledgement
Confidentiality Commitment: I acknowledge that the red light therapy facility commits to maintaining the confidentiality and privacy of all personal and health information provided in this form. Information will only be used to evaluate suitability for red light therapy use and manage my experiences appropriately. *
Data Usage: I consent to the collection, use, and, where necessary, the disclosure of my personal information as needed for the provision of red light therapy services. This may include sharing information with healthcare professionals under circumstances that require medical intervention.*
Rights to Access and Correction: I understand that I have the right to request access to my personal records held by the facility and can request corrections to any inaccuracies in my personal data.*
Security Measures: I acknowledge that the facility implements appropriate security measures to protect my personal data from unauthorized access, alteration, or destruction.*
