Hyperbaric Oxygen Therapy (HBOT) Consent & Overview

Light and Vibration Therapy – PSIO Consent Form

PSIO Consent Form

Patient & Provider Information

Patient Name
Patient Name
First Name
Last Name

Introduction / Purpose

Light and Vibration Therapy using the PSIO system combines targeted light frequencies (via therapeutic glasses) with gentle vibrational therapy (via the chair) to promote relaxation, stress reduction, improved sleep, cognitive performance, and mood regulation.

Intended benefits may include:

  • Improved sleep quality and circadian rhythm
  • Enhanced focus and mental clarity
  • Reduced stress and anxiety
  • Mild relief from tension headaches or eye strain

Treatment Overview / How It Works

  • Patient is seated in a specially designed chair, head positioned comfortably with PSIO glasses
  • Light frequencies are applied through the glasses; vibrations are delivered through the chair
  • Session duration: 15–20 minutes
  • Session frequency is based on individualized treatment plan

Contraindications & Warnings

Do not use PSIO Therapy if you have:

  • Epilepsy or photosensitive seizure disorders
  • Pregnancy (first trimester precaution recommended)
  • Severe eye conditions (retinal detachment, recent surgery, or severe glaucoma)
  • Pacemaker or implanted electronic devices (consult provider)

Caution is advised for patients with:

  • History of migraines triggered by light or vibration
  • Severe cardiovascular or neurological conditions

Possible Risks / Side Effects

  • Temporary eye strain, mild headache, or dizziness
  • Mild tingling or vibration discomfort
  • Rare: nausea or light sensitivity
  • Symptoms generally resolve shortly after the session

Pre-Treatment Instructions

  • Sit comfortably and remove any glasses or reflective objects
  • Avoid caffeine or stimulants immediately before the session
  • Inform the provider of any neurological, ocular, or cardiovascular conditions

During Treatment / Application

  • Patient remains seated with head in PSIO glasses
  • Provider monitors comfort and adjusts light intensity or vibration if necessary
  • Patient should inform provider immediately of any discomfort

Post-Treatment / Aftercare

  • Mild relaxation or drowsiness may occur; allow time to adjust before driving
  • Drink water and follow any additional instructions provided
  • Report any unusual symptoms within 24 hours

Patient Responsibilities

  • Remain seated and follow provider instructions during the session
  • Report any discomfort or pre-existing conditions before and during therapy
  • Follow recommended session schedule for best results

Acknowledgment & Consent

I acknowledge that:

  • I have read and understood this consent form
  • I understand the benefits, risks, and alternatives of PSIO Light and Vibration 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

Final Acknowledgment

By Submitting the form :

  • I understand that PSIO Therapy involves risks and outcomes may vary.
  • I understand that I am paying for professional services, not a guaranteed result.
  • I acknowledge that multiple sessions may be required for optimal results.
  • I release AI Wellness Center of Excellence from liability for adverse outcomes except in cases of gross negligence.