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LED Cube Light History & Consent 

The Cube Light is an LED device for light emitting diode therapy. It has 6 different wavelengths of light to treat different skin disorders and can be used for face, scalp and body treatments.

RED Light penetrates the epidermis and has been shown to stimulate the production of collagen and elastin and so helping to reduce the appearance of fine lines and wrinkles. Red LED light is also thought to improve blood circulation and help with the absorption of active ingredients.

BLUE LED light can reduce activity in the sebaceous glands, help to reduce the appearance of blemishes and promote a calmer, clearer-looking complexion.

GREEN light has a calming effect and can help lighten age spots, sun damage and hyperpigmentation for a brighter, more even complexion.

YELLOW light is used to help soothe rosacea, flushed skin and redness. It can also help reduce melanin production.

SCALP DIODE can be used to support hair loss treatments. It improves blood circulation and helps stimulate the hair follicles.

IR (barely visible near infrared light) penetrates even deeper that red light and triggers wound healing, decreases inflammation, and can help with pain relief and muscle relaxation.

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Disclaimer:

Please ensure that all consent forms are relevant to you as a practitioner and verified by your insurance company.


It is your responsibility to ensure your consent form is correct.


Prior to receiving treatment, please reveal any conditions that may have an effect on this treatment. If you are unsure of any details including personal requirements and potential complications, please discuss with your practitioner.

Please complete the following questionnaire:

Are you currently under a doctor’s or specialist’s care?
Yes
No
Do you take any over-the-counter or prescription medication or herbal/natural remedies on a regular basis?
Yes
No
Do you have any current chronic or serious medical illnesses such as diabetes, heart disease/angina, epilepsy or seizures triggered by light, thyroid condition, hepatitis, blood disorders, cancer?
Yes
No
Do you have any autoimmune or metabolic diseases such as psoriasis, lupus, rheumatoid arthiritus or any condition that may weaken your immune system.
Yes
No
Do you have any known allergies?
Yes
No
Do you have any skin conditions such as acne, rosacea, seborrhoea, facial cold sores (herpes simplex), moles, warts, vitiligo, contact dermatitis or inflammatory skin diseases?
Yes
No
Do you have or have had any form of cancer?
Yes
No
Are you currently receiving chemotherapy or radiotherapy?
Yes
No
Have you taken medication for acne such as oral retinoids (Roaccutane) or benzoyl peroxide in the last 6 months?
Yes
No
Are you currently taking topical or systemic steroids (NSAIDs) or having cortisone injections?
Yes
No
Do you suffer from light induced headaches or migraines?
Yes
No
Do you have any photosensitive disorders such as porphyria, lupus erythematosus, photosensitive eczema and albinism?
Yes
No
Do you have any genetic eye conditions?
Yes
No
Have you used any products containing topical retinoids (Vitamin A, Retinol, Retin A etc) in the last week?
Yes
No
Have you used any exfoliants or products containing alpha hydroxy (AHAs), beta hydroxy (BHAs) acids (such glycolic acid, lactic acid, fruit acids) or hydroquinone in the last week?
Yes
No
Have you had any recent facial surgery or aesthetic treatments such as rhinoplasty, face lift, dermal fillers, PDO threads, Botulinum toxin, aesthetic dental work, tattoos, piercings, laser resurfacing, laser hair removal, micro needling or skin peels?
Yes
No
Have you had electrolysis, depilatory creams, or waxing on the area to be treated in the last week?
Yes
No
Have you had any recent sunburn, windburn, cuts or skin abrasions?
Yes
No
Do you smoke?
Yes
No

For women:

Are you pregnant or is there any possibility that you are pregnant?
Yes
No
Not Applicable
Are you breastfeeding?
Yes
No
Not Applicable
Are there any other aspects of your health that have not been identified above and we should be made aware of?
Yes
No
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I confirm that I understand the risks and conditions associated with an LED (light emitting diode) treatment and that it is an elective cosmetic procedure.


The LED light treatment is typically used to improve the clinical appearance of the skin and help resolve problem skin conditions.


During the treatment, some clients report a slight tingling sensation and flashing of the optic nerve.


After the treatment, the skin may experience:


  • Redness

  • Tighteness

  • Slight swelling

  • Temporary irritation


These temporary skin responses will typically subside within hours and most people are able to return to their normal activities the same day.


Some people may react differently and may experience these reactions for longer. However, these reactions are temporary and usually resolve within 24 hours as the skin returns to normal.


Although rare, there is a small risk of reactions including nausea, dizziness, weakness, and possible skin reactions including redness and/or irritations.


Any prolonged redness of the skin, swelling, itching or severe headaches are indications of light sensitivity. These should be immediately reported to your practitioner and the sessions discontinued.


There is a greater risk of sunburn and a small risk that skin discolouration (hyperpigmentation) of the skin can occur after the procedure, if sunscreen is not worn daily.


I have been given the following post treatment advice:


  • Drink plenty of water.


  • Refrain from saunas, steam baths and hot showers for 24 hours.


  • Avoid high impact aerobic exercise or vigorous physical activity for 24 hours after treatment.


  • Avoid intensive sun exposure and tanning booths while undergoing treatment and up to 2 weeks following your sessions.


  • Use daily sunscreen protection with a minimum of 30 SPF for at least 2 weeks after treatment.


  • Use of an intensive moisturiser is advised for at least a week as skin may feel drier or tighter after treatment.


  • Any concerns should be reported to your practitioner as soon as possible.


I confirm that I understand the risks and conditions accociated with this treatment and that it is an elective medicalcosmetic treatment.


I confirm that the medical history and medication details that I have supplied are complete and correct and that there is no other medical information I need to disclose.


I understand that withholding any medical information may be detrimental to my health and safety during the treatment in which I agree to undertake.


If there is any change in my medical history, it is my responsibility to advise the practitioner before further treatments are carried out.


I understand that there are certain contraindications that would preclude me from receiving treatment including pregnancy, epilepsy or seizures triggered by light, a thyroid condition, suspicious lesions, malignant tumours, cancer, open wounds in the area to be treated, use of topical or systemic steroids (NSAIDs) or cortisone injections, a history of drugs or

supplements with photosensitizing potential*, use of topical treatments such as retinoids that cause sensitivity to sunlight, photosensitivity disorder, light sensitive headaches or migraines, auto immune and metabolic disorders which can result in light induced rashes, any genetic condition of the eyes.


I confirm that I understand the risks and conditions associated with the treatment. These have been fully explained to me and I have had the opportunity to ask any questions and these have been answered to my satisfaction.


Development of any reactions must be reported to the practitioner as soon as possible.


I accept and understand that there are no written, implied, or verbal guarantees as to the anticipated results of this treatment and that the effects of treatment will vary with some patients than with others and that the goal of this treatment is improvement, not perfection.


I may require a series of treatments, normally one week between procedures, to achieve the maximum cosmetic result.


I have been given post treatment advice and I understand and agree to follow all the care instructions carefully to minimise the risk of side effects.


I confirm that I have been allowed sufficient time to make a carefully considered decision.


I consent to the taking of (pre and post-treatment) photographs to monitor treatment effects.


Complete patient confidentiality will be maintained at all times.


I understand that I am free to withdraw my consent at any time.


I have read the above consent, and I confirm that by signing this form I consent to undergo treatment and I take responsibility to inform of any change in my medical history.


* Medication and supplements that can cause photosensitivity include acne medication, diuretics, certain antibiotics, anti-arrythmic drugs, epidermal growth factor receptor inhibitors, non-steroidal anti-inflammatory drugs, anti-fungals, anti-psychotics, anti-arthritic medication, St John’s Wort, psoralen. Please note, this is by no means a complete list of all photosensitive medications. If in doubt please consult your GP.

I also consent (please tick as applicable) to these photographs being used for:
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