I hereby request and consent to the performance of assessments, various modes of physical therapy, laser therapy, and other procedures, on me by the practitioners listed at this clinic and or anyone working at this clinic authorized by the practitioners. I have had the opportunity to discuss the nature and purpose of assessments, various modes of physical therapy, laser therapy and other procedures.

I understand that results are not guaranteed. I understand that Deep Tissue Laser Therapy is a medical treatment that uses specific wavelengths of light to impart energy into injured cells and tissues. This energy is transformed from photon energy to biochemical energy in the cells which can then be used for repair processes in the body. The expected direct outcomes from laser treatment may include reduced inflammation, reduced pain, and increase the healing process. The indirect outcomes may include increased ranges of motion, comfort, and activity levels. I further understand and am informed that, as in all health care, in the practice of laser therapy there are some risks, including but not limited to, short term aggravation of symptoms and skin irritation. When used in combination with certain medications laser therapy can cause rashes or burns and I therefore understand that I must disclose all information on my current medications to the practitioners at this clinic.

I understand that I must disclose any history of cancer. I also understand that the laser can cause damage to the eyes when viewed directly and that laser safety eyewear, supplied by this clinic, must be worn by me during laser treatments. I consent to the assessments, various modes of therapy, including but not limited to laser therapy, offered, or recommended to me by the practitioners in this clinic. I intend this consent to apply to all my present and future care in this clinic.