Red Light Therapy Consent Form:

Waiver & Release:

Effective 12.12.2024 @ Pella Pilates & Wellness, LLC

Why You’re Reading This Document

The purpose of this release & waiver (the “Waiver”) is to openly communicate the risks of RED LIGHT THERAPY either in person or online & have you release Pella Pilates & Wellness of any liability.

Please be aware that if you do not sign this Waiver & agree to its terms, you will not be permitted to use the red light therapy panel.

If you are under the Age of Majority, your legal guardian must sign this Waiver on your behalf.

After you have read each section, please initial each box below and type your name at the end of the document.

UNDERSTANDING:

I hereby agree to use the red light therapy panel at Pella Pilates & Wellness upon the understanding & condition that I should stop immediately if I detect discomfort of any sort during the course of using red light therapy. PLEASE READ CAREFULLY, UNDERSTAND FULLY, & ASK QUESTIONS IF ANYTHING IS UNCLEAR. WE ARE HERE TO SUPPORT YOU. MAKE SURE YOU UNDERSTAND THIS WAIVER. BY SIGNING THIS YOU AGREE YOU ARE SIGNING AWAY YOUR LEGAL RIGHTS & YOU AGREE TO BE BOUND BY ALL THE TERMS OF THIS WAIVER.

First Name

Last Name

MEDICAL CONDITIONS:

Red light therapy (RLT) is generally considered safe for most people, but there are several contraindications and precautions to be aware of. Here's a detailed list of contraindications and considerations: 1. Pregnancy Due to insufficient studies on the safety for pregnant individuals, we do not allow women who are pregnant to use RLT. 2. Photosensitivity If you have a condition or are taking medications that increase photosensitivity (e.g., tetracyclines, sulfonamides, psoralens, certain acne treatments like isotretinoin, or herbal supplements), you may be at risk for skin reactions or burns. Consult your doctor before use. 3. Cancer Avoid using red light therapy on areas where cancer is active or if you have a history of skin cancer, as the therapy can stimulate cellular activity. Consult with your oncologist if you are undergoing cancer treatment before use. 4. Epilepsy Although RLT devices typically emit steady light rather than flashing, those with epilepsy or sensitivity to light stimulation should consult a healthcare provider before use. 5. Over Wounds or Infections While RLT is sometimes used to aid wound healing, using it over infected wounds or open sores without medical advice could potentially worsen the condition. 6. Tattoos and Recent Cosmetic Procedures Areas with tattoos may react unpredictably due to pigments absorbing light. Similarly, avoid RLT after recent cosmetic procedures (e.g., chemical peels, laser treatments) until the skin has fully healed. 7. Severe Skin Conditions Conditions like eczema, psoriasis, or rosacea might react to RLT differently. While some users report benefits, others might experience flare-ups. Always consult a dermatologist before use. 8. Heart Conditions or Pacemakers Avoid direct use over the chest area in individuals with heart conditions or pacemakers, as the effects of RLT on such devices are not well-documented. Consult with your healthcare provider before use. 9. Eye Safety Avoid looking directly into the light source, as it may damage the eyes. Use proper eye protection if treating areas near the face. 10. Children While RLT can be beneficial for specific conditions in children, parents or legal guardians must consult with their medical professional before use. 11. Heat Sensitivity People with conditions that impair heat sensitivity or sensation (e.g., neuropathy) should exercise caution, as they may not notice overheating of the treated area. Consult your medical provider before use. General Precautions Device-Specific Guidelines: Never go closer than 6 inches to the device. I understand that misusing this device can lead to burns or other skin damage. Skin Reactions: Discontinue IMMEDIATELY if you notice redness, irritation, or discomfort during or after treatment. Consult a Professional: Always check with a healthcare provider if you're unsure whether red light therapy is appropriate for your condition or situation. By signing I acknowledge these health concerns with using RED LIGHT THERAPY:

CURRENT MEDICATIONS

Some medications and conditions may contraindicate red light therapy. These include: Medications that increase light sensitivity like antibiotics, St. Johns Wort, lithium, melatonin, and phenothiazine antipsychotics. Steroids and anti-inflammatory drugs cancel out the therapeutic benefits of red light therapy. Retinal diseases and medications.

PREGNANCY AND EPILEPSY NOT PERMITTED TO USE RED LIGHT THERAPY

YOUR SCHEDULED TIME

You have your scheduled session block plus 5 minutes to change and disinfect the area. MUST cancel 24 hours in advance or you will be charged for your session. DO NOT COME if you have had fever or stomach virus within 24 hours of your appointment (late charge waived). Please keep track of time to be courteous of the appointment after you.

RELEASE, WAIVER, AND IDEMNITY

You hereby release, hold harmless, indemnify, defend & waive any claims against Pella Pilates & Wellness, LLC, its members, directors, officers, contractors, employees, volunteers, agents, executors, administrators, successors, family members & assigns (the “Released Parties”) from and against any and all liability & damages, including attorney’s fees, arising from death or personal injuries, including the contraction of COVID-19 or other communicable diseases or related to premises liability, however caused including as a result of Pella Pilate’s negligence, during your usage of the red light panel at Pella Pilates. You are releasing the Released Parties at your own risk & you agree to forfeit any & all forms of legal recourse which may be available to you, including but not limited to any form of damages, as a result of your usage of the red light panel. You agree that this provision applies to you, your family, heirs, executors or anyone else who may be able to bring a legal action on your behalf in the future.

VOLUNTARY PARTICIPATION AND UNDERSTANDING

I understand that RED LIGHT THERAPY is not intended to take place of medical care or medications. I understand that I take full responsibility for my own health and well-being. I acknowledge that the results of red light therapy use do vary, and that no guarantees of specific results are offered or implied. Pella Pilates & Wellness, LLC will not refund or credit any amount of money because of a client’s unhappiness with their results. I agree to hold Pella Pilates & Wellness, LLC and all authorized representatives harmless from any liability involved in the use of red light therapy. Pella Pilates & Wellness, LLC and their staff have explained this treatment to me and all my questions, if any, were answered. I have reviewed and completely understand this form.

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EMERGENCY CONTACT INFO:

PLEASE LIST NAME, RELATIONSHIP, AND PHONE NUMBER

CLIENTS UNDER 18

No clients under the age of 18 are permitted to use red light therapy unless accompanied by a supervising adult. If a minor would like to use red light therapy, a Parent/Legal Guardian of the listed minor must acknowledge that you have read and understood the safety standards and warnings provided to me by Pella Pilates & Wellness and thereby authorize the minor to use the red light therapy. You acknowledge that you have read and completely understand this consent form, and agree to the above waivers of liability, recommendations and terms. You attest that you have provided accurate age, identity and relationship verification.