Consent Form

Schedule Your Visit Today

LED Consultation & Consent Form

LED is a procedure that is designed for skin rejuvenation, pain reduction and wound healing. Light photons are absorbed by the cells to create ATP (cellular energy).

Informed Consent for Teeth Whitening Treatment

LED treatment is a procedure designed for rejuvenation and wound healing via bio-stimulation effect.
The LED device will be applied over the area of the treatment and the procedure may take 20 – 30 min
Risks:

All forms of health treatment, including LED, carry some risks and limitations. Complications that may occur in professional LED are very infrequent and are usually minor in nature.

  • Epidermal Tone Change: During the treatment process, some patients who are darker skin can experience epidermal darkening by one shade. This is normal and generally mild and only last an hour or two. This is due to higher absorption capabilities of darker skin types.
  • Burn: This is generally due to the gel un-protected sun exposure in the last 2 weeks of the procedure or using AHA or BHA peels before the LED procedure on the same day.

Precautions and Contraindications for treatments

There are some instances in which the LED Light Therapy may prove unsuitable for an individual when taking certain drugs or medical conditions, this may mean that an individual is unsuitable for the treatment.

Precautions due to drug induced photosensitivity. Please indicate if you are or have taken any of the following medication

  • Antibiotics
  • Tetracyline group: Doxyclyline, Oxytetracycline etc
    Quinolone group: Ciprofloxacin, Ofloxacin, Levofloxacin
    Sulfonamides: sulfamethoxazole/trimethoprim
    If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Naproxen, Celecoxib
    If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days

  • Diuretics
  • Furosemide, Bumetanide, Hydro-chlorothiazide
    If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days

  • Retinoids
  • Roaccutane/accutane
    If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days

  • HMG-CoA reductase inhibitors
  • Statins (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin)
    If yes, the treatment can still be administered at the discretion of the patient as long as they report no increased sensitivity to sun since commencing statins

  • Epidermal growth factor receptor inhibitors (treatment for lung cancer)
  • Cetuximab, panitumumab, erlotinib, gefitinib, lapatinib, vandetanib
    If yes, please consult your physician before commencing a course

  • Antifungals
  • Terbinafine, Itraconazole, Voriconazole, Griseofulvin (Grisovin)
    If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days

  • Anti-Arrhythmic drugs
  • Codarone, Aratac, chlorpromazine
    If yes, it is at your discretion whether you commence a treatment

  • Anti-arthritic
  • Ridaura, Gold 50
    If yes, the treatment cannot be administered

  • Anti-arthritic
  • Azathioprine
    If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days

  • Anti-Cancer drugs
  • Ledertrexate/Methotrexate
    If yes, the treatment can be administered as long as the medication has not been taken in the last 5 days

Precautions and Contraindications for treatments There are some instances in which the treatment may prove unsuitable for an individual.

  • Are you Pregnant? Yes / No
  • Do you suffer from epilepsy or seizures triggered by light? Yes / No
  • Do you suffer from a photosensitive disorder? Yes / No
  • (A photosensitive disorder describes a condition which means that you are sensitive or react to normal amounts of light. Photosensitive disorders include Porphyria, Lupus erythematosus, photosensitive eczema and Albinism).

If you answered yes to any of these questions, then unfortunately you are not suitable

  • Do you suffer from light induced migraines? * Yes / No
  • Are you currently taking St John’s Wort or other herbal remedies? * Yes / No

If you answered yes to question 4 or 5, then it is at your discretion whether you commence a treatment.

*Although uncommon the light may induce a migraine attack.

*St John’s Wort taken in very large amounts (more than the RDA) may cause some people to be slightly more sensitive to light.
Consent:

I understand that the final result of my LED treatment cannot be guaranteed.
I understand that after the treatment, I will be required to refrain from un-protected sun exposure.
I have read all of the above and had all my questions satisfactorily answered. In signing this informed consent, I am stating I have read the informed consent information and I fully understand the possible risks, complications and benefits that can result from the LED system.
Note: Do not sign this form until you have read and understood all of the above.

0
    0
    Your Cart
    Your cart is emptyReturn to Shop

    schedule A Visit