LOW LIGHT LASER THERAPY (LLLT) CONSENT FORM

Please complete this form thoroughly before your treatment

Personal Information

Medical History

Contraindications

Please read through the list of contraindications and tick any that apply to you:

LLLT has not been thoroughly studied for safety during pregnancy or breastfeeding. Therefore, it is not recommended for individuals in these conditions.

Individuals who are highly sensitive to light or have a history of photosensitivity reactions should not undergo LLLT. Common conditions associated with photosensitivity include: Lupus (Systemic Lupus Erythematosus), Porphyria

The following medications can cause heightened sensitivity to light, increasing the risk of irritation or burns: Antibiotics (e.g., tetracyclines, fluoroquinolones), Retinoids (e.g., isotretinoin), Diuretics (e.g., thiazides), Non-steroidal anti-inflammatory drugs (NSAIDs, e.g., ibuprofen, naproxen), Antifungal medications (e.g., griseofulvin), Antidepressants or antipsychotics (e.g., tricyclic antidepressants, phenothiazines)

Infections or skin disorders of the scalp, such as: Psoriasis with open sores or inflammation, Fungal or bacterial infections, Severe seborrheic dermatitis, Eczema or other lesions

History of cancer may be a contraindication for LLLT treatment.

LLLT devices that emit flashing lights may trigger seizures in individuals with photosensitive epilepsy.

Conditions such as Alopecia Areata, an autoimmune hair loss condition, may not respond well to LLLT. Patients with active autoimmune disorders should consult their healthcare provider.

If you have a history of keloid scarring or poor wound healing, LLLT may not be suitable.

Treatment over a heavily tattooed or pigmented scalp can lead to altered or diminished effects due to light absorption in the pigment.

LLLT may not be recommended for individuals under 18 unless prescribed by a healthcare professional.

Treatment Analysis

Informed Consent

By signing this form, I acknowledge the following:

Purpose of Treatment

Low Light Laser Therapy (LLLT) is a non-invasive treatment designed to stimulate hair growth and improve the quality of hair through the use of specific wavelengths of light. LLLT has been shown to promote hair growth in certain individuals experiencing hair thinning or hair loss.

How LLLT Works

LLLT uses low-level lasers or light-emitting diodes (LEDs) that penetrate the scalp, improving cellular function and stimulating the hair follicles. Treatment efficacy varies by individual and may depend on factors such as the degree of hair loss, underlying causes, and adherence to the treatment schedule.

Potential Benefits

  • Stimulation of hair follicles for new hair growth
  • Improvement in hair density and strength
  • Reduction in hair shedding

Possible Risks and Side Effects

While LLLT is generally safe and well-tolerated, potential risks and side effects may include:

  • Mild scalp discomfort or irritation
  • Temporary redness or warmth of the treated area
  • Potential for minimal improvement in hair growth

Treatment Schedule and Recommendations

The standard treatment plan requires a commitment to at least 16–24 sessions over a period of 3–6 months, with treatments scheduled 2–3 times per week.

Declaration

I have read and understood the information provided in this consent and consultation form. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. By signing below, I consent to the use of the Follicle Former LLLT device and confirm that I have disclosed any contraindications or concerns.