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LED light therapy Consent Form

This is an informed consent form that has been prepared to help inform you of the potential benefits and risks of LED light therapy. It is important that you read this information carefully and discuss fully with your practitioner before proceeding with treatment.

It is also important that you take as much time as you need to consider the treatment carefully, weighing up all your options before reaching an informed decision. It is essential that you are aware of your right to have a second opinion and you are encouraged to ask any questions that come to mind throughout the entirety of the process.
LED light therapy is a new technology used for skin rejuvenation and the treatment of some skin lesions, it is based on narrowband Light-emitting Diodes (LEDs) and the energy from the LED light has a therapeutic effect on the skin. LED light therapy can be used for the treatment of a wide range of dermatological conditions including, acne, photodamage, non-melanoma skin cancers, skin rejuvenation, vitiligo, and wound healing post elective surgery. Each detachable treatment head delivers pure, optimised, narrowband light via a matrix of LEDs carefully positioned to deliver light to the treatment area.
Note that LED light therapy used to treat skin cancers or pre-cancerous skin lesions should be carried out only by a qualified medical doctor.
The advantages of LED light therapy include:
• Stimulates the body’s cellular mechanisms by photomodulation
• Not a laser or an IPL so no heat, no side effects or downtime.
• Non-invasive, non-ablative safe therapy
• No damage to sub-dermal tissue
• Treatment is painless
Treatment involves placement of the light handpiece over the treatment area and you will be given safety goggles to wear to protect your eyes. Duration of treatment is about 20 minutes for each body part or the size of an average face. The treatment is painless and you will not require any topical anaesthetic cream. For optimal results, you will need 8-12 treatments done at intervals of 3-4 weeks. I am aware that results vary between clients and results are dependent on many individual factors. I am aware that there is no guarantee that I will achieve desired results and that multiple treatment courses may to be needed to achieve or maintain desired results. Aftercare advice includes avoiding sun exposure and tanning booths and using SPF sunscreen daily, there is no downtime after treatment.
I understand that several appointments may be necessary to produce optimal results and I will be notified, in advance of each session of treatment, about the location where the next treatment session is going to take place and the identity of who is going to be involved in my care at each stage. I also understand that I will be kept informed of progress and that I can change my mind at any point.
RISKS AND SIDE EFFECTS: Risks, side effects, and complications: LED light therapy has been shown to be safe, no trails have shown any serious side effects. Treatment however may be ineffective with advanced and resilient skin problems. You must also wear eye protection during the procedure to protect your eyes from the bright light. There have been incidental reports of post-treatment irritability, headache, nausea, eye strain, rash and skin redness, if you notice any of these symptoms you must contact your practitioner. There is no link between LED light therapy and increased risk of skin cancer.
I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice. This includes advice about:
- the aims/motivations for having the procedure and the desired outcome
- the risks inherent in the procedure
- the risks inherent in refusing the procedure
- the risks specific to me
- the expected benefits of the treatment
- the potential disadvantages of the treatment
- alternative procedures and their pros and cons - including the option of no treatment at all
- any uncertainties about and the likelihood of success of the procedure
- any follow-up treatment that may be required
CLINICAL PHOTOS AND VIDEOS: I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records.
I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision.
I hereby consent to LED Light Therapy. This treatment has been explained to me and I have had the opportunity to ask questions regarding the procedure. I understand that these treatments are not an exact science and the degree of my improvement is variable.
By my signature below, I acknowledge that I have read the information and consent and that I have been allowed to ask questions and that my questions have been answered to my satisfaction. I have been adequately informed of the risks and benefits of this treatment and I wish to proceed with the LED Light Therapy.
I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.
Date / Time
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The following aftercare advice is essential to help reduce the risk of treatment
complications, to improve your comfort/healing and to help achieve the best possible
results from treatment.
Please follow the aftercare advice for LED light therapy treatment.
• Immediately after treatment, there may be redness and mild swelling at
the treatment site, your skin may feel like mild sunburn. These effects
usually resolve within 48 hours. If you are concerned the effects are not
resolving, then you must contact your practitioner.
• Do not pick, scratch or rub the treated area because this may cause skin
• Avoid makeup for 24 hours after treatment. Wait until any redness and
swelling has resolved before applying.

• Cleanse your skin twice a day with warm water. Use a gentle moisturiser
regularly on your skin.
• Avoid any excess sun exposure or sunbeds for 48 hours after treatment,
use an SPF 30 sunscreen.
• Avoid any irritants to your face, such as any products containing Retin-A
(tretinoin), retinol, benzoyl peroxide, glycolic / salicylic acids, astringents
or chemical peels for at least 7 days after treatment.
• Avoid any hair removal procedures such as waxing for 2 weeks.
• Do not exercise, receive any body treatments, take hot showers, or use
saunas or hot tubs until redness and swelling has resolved (usually 2

• Contact your practitioner as soon as possible if you experience any
unwanted side effects or if you are concerned about healing.

• Your practitioner will advise you when follow up appointments are needed.
If you are advised to attend a follow up appointment, please do make every
effort to attend them. You should do this even if you believe that the
recovery process is going well and you cannot see that there are any visible

It is essential that you have read all of the information available. Once you have
read and understood all of the below, please sign the declaration at the bottom of
this form. Please do let your practitioner know if you have any questions or if you
do not understand any of the aftercare instructions provided below.
I confirm that I have read and understood all the information on this Form and that
I have been given the opportunity to ask any questions that have come to mind

Date / Time