Class IV Laser Therapy Consent Form

Class IV Laser Therapy Consent Form

Patient & Provider Information

Introduction / Purpose

Class IV Laser Therapy uses a 30-watt FDA market-cleared laser (810nm + 980nm) to provide therapeutic benefits including analgesia, tissue repair, improved circulation, and increased cellular activity. Pulsed and continuous modes allow optimal tissue penetration and minimize overheating.

This therapy is commonly used for musculoskeletal conditions, dermatologic applications, orthopedic rehabilitation, and physical therapy.

Treatment Overview / How It Works

  • Delivered using a handheld, user-friendly device with customizable presets for tissue depth, skin color, and body size

  • Typical session duration:

    • Acute conditions: 5–10 minutes per area

    • Chronic conditions: 10–15 minutes per area

  • Frequency:

    • Acute: daily or every other day

    • Chronic: 2–3 times per week, decreasing as improvement occurs

  • Dosage adjusted based on condition severity: 6–10 J/cm² for acute conditions, 10–15 J/cm² for chronic conditions

Contraindications & Warnings

Do not use Class IV Laser Therapy if you have:

  • Active cancer in the treatment area

  • Pregnancy (over abdomen or pelvis)

  • Photosensitivity or use of photosensitizing medications

  • Open wounds or infections at treatment site

Caution is advised for patients with:

  • Epilepsy triggered by light

  • History of skin sensitivity or neuropathy in the treatment area

Safety measures:

  • Protective eyewear is required for both patient and provider

  • Avoid direct eye exposure to the laser

  • Continuous monitoring of patient comfort

Possible Risks / Side Effects

  • Mild warmth, tingling, or temporary redness at the treatment site

  • Rare: burns, blisters, or exacerbation of existing skin conditions

  • Discomfort if settings are too high or patient moves during treatment

Pre-Treatment Instructions

  • Clean and expose the treatment area

  • Remove any jewelry or reflective items

  • Inform provider of any skin conditions, medications, or implants in the treatment area

During Treatment / Application

  • The provider will operate the laser according to clinical protocol

  • Patient may feel mild heat or tingling

  • Report any discomfort immediately

Post-Treatment / Aftercare

  • Mild redness or warmth may occur, usually resolving within a few hours

  • Avoid applying creams or oils to the treatment area for at least 2–4 hours unless instructed

  • Follow any stretching, movement, or rehabilitation exercises prescribed by the provider

  • Schedule follow-up sessions as recommended

Patient Responsibilities

  • Adhere to pre- and post-treatment instructions

  • Notify provider of any unusual reactions

  • Attend all recommended sessions for optimal outcomes

Acknowledgment & Consent

I acknowledge that:

  • I have read and understood this consent form

  • I understand the benefits, risks, and alternatives of Class IV Laser Therapy

  • I consent to the treatment and accept responsibility for my own safety

  • I release AI Wellness Center of Excellence, its staff, and affiliates from any liability except in cases of gross negligence or willful misconduct

I consent to photos or video for educational or promotional purposes, if applicable