Patient’s name:

Patient ID: Address

Age:                     Gender: Male / Female In case of females- LMP Lactating- Yes/No

Occupation:

City/ Clinic Branch: Doctor Incharge:

Date:  Time:

LOW LEVEL LASER LIGHT THERAPY (LLLT) FOR HAIR DISORDERS

Instructions- This consent form should be signed by the patient if an adult (18 years or older); by a parent /guardian
if the patient is a minor.

Light used (colour/ wavelength) - Low level Laser light________ Time___________________

Treatment Area – __________________

I____________________________, {(the patient) or representative of the patient ________________}, have

● Read
● And/ Or have read and explained this consent form to me in a language which I fully understand, and have
understood the information provided below in this consent form.
_____________________________________________________________
(Full name of procedure, Use no abbreviations/Avoid Technical Terms)

Brief description of procedure:

Low-level laser therapy (LLLT) is a form of treatment that applies low-level (low power) lasers,
especially of red(650nm), blue(450nm) and pink(combination of blue and red), yellow(580nm)
lights of different wavelengths on the surface of the skin and hair for various indications. They
help by stimulating formation of new cells thereby are used for wound healing, hair loss, skin
rejuvenation. They also help in reducing inflammation, swelling and redness. Therapeutic
response is due to photothermic effects in which light energy acts on tissue which is converted
into heat energy. Thermal energy brings about biological changes in cells like stimulating the
cells, hair follicle, also growth of stem cells, so it helps in accelerating the hair cycle, skin
remodelling.
Laser procedure is performed in a safe and precise manner. The procedure is normally completed
within 10-30 minutes, but it can take longer depending on the required treatment and type of
condition being treated.
Multiple sessions may be required based on the severity of the condition or type of hair loss.
The total number of treatment sessions may vary among individuals and an exact number of
sessions cannot be predicted. The condition may continue to improve till 1 months – 3 months
after a treatment. Even after multiple sessions, the complete eradication of the problem may not
happen and maintenance sessions may be required for maintaining the improvement.

Patient Initials _______

Laser light therapy may need to be combined with other procedures like Mesotherapy,
PRP etc.
Intended benefits:
It reduces inflammation, edema. hair loss, sebum production helps in rejuvenation, repair by
stimulation of stem cells. It is well known that all procedures inherently carry a possibility of
certain risks. The potential risks and complications from the procedure include but are not
limited to the following-
1. Redness/ Erythema- seen occasionally which subsidies in 2-5 days .
2. Additional side effects:  There are risks associated with any procedure.  Since, it is
impossible to state every risk or complication that may occur as a result of treatment, the
possible risks and complications listed here may be incomplete.  There may be risks or
complications associated with this treatment that are not yet reported in the literature
3. Other Major Risks Involved _______________________________________________
Consent-
1. I am now aware of the intended benefits, possible risks & complications, and available
alternatives to the said procedure. I am aware that while the majority of patients have an
uneventful procedure and recovery, few cases may be associated with complications. I am aware
of the common risks and complications associated with this procedure and understand that it is not possible
to list all possible risks and complications of any procedure. I am advised that though good results are
expected, the possibility and nature of complications cannot be accurately anticipated. I am also informed
that complication/s can occur despite due and reasonable care and caution as some complications are
beyond the control of the attending therapist and/or the dermatologist or dermatosurgeon. Therefore,
there can be no guarantee as expressed or implied either as to the success or any other result of the
treatment.
2. I am also aware that results of any procedure can vary from patient to patient and I declare that no
guarantees have been made to me regarding the success of this procedure. I understand that although I may
see a change after my first treatment, I may require a series of sessions to obtain my desired outcome. The
need for this cocktail treatment has been explained to me along with the possible downtime, side-effects
and possible complications of the treatments recommended.
3. I am aware that the above said treatment(s) is not permanent as natural degradation will occur over time.
4. I also understand that sometimes a planned procedure may need to be postponed or cancelled if a patient's
clinical condition demands or due to any unforeseen technical reason. I am also aware that I can withdraw
my consent at any point of time at my own risk and consequences, by submitting the withdrawal in writing.
I understand that if medical emergencies or patient treatment demands, further or alternative procedural
measures may need to be carried out and in such cases there may be differences in the planned and actual
procedure.
5. I am now also aware that during the course of this procedure, the doctor will be assisted by a medical and
paramedical team, and that the doctor may seek consultation/assistance from relevant specialists if the need
arises.
6. Photography-I agree to the procedure (including my diagnosis /reports pathology, radiology, etc) being
photographed (still/video/televising) for academic /medical/medico-legal purposes, provided my identity is
not revealed by such acts. I also agree to my clinical details being shared for scientific publications if my
identity is not disclosed.
7. I am also aware of the expected course after the procedure and the post procedural care to be taken.
8. I declare that I have received & fully understood the information provided in this consent form, that I have
been given an opportunity to ask any questions relating to my ailment, the procedure being performed, its
risks, consequences, alternatives, potential complications, intended benefits and recovery time and that all

Patient Initials _______

 my questions have been answered in a satisfactory manner and there are no misconceptions or false hopes
in my mind.
9. I further declare that all fields (of this form) requiring insertion or completion were filled in my presence at
the time of my signing this form.
10. For the above mentioned operation (s)/procedures(s) that I have been made aware of, I give my consent
voluntarily to Dr.____________________________________________  and/or the trained therapist under
the supervision of the dermatologist for carrying out the said procedure on [ ]myself or [ ]above named
patient being fully aware of the nature, potential risks and complications, intended benefits and possible
alternatives.
11. I, above named patient or representative of the patient, do further hereby declare that I am above 18 years
of age as on the date of signing this form, mentally sound and am giving consent without any fear, threat or
misconception.
12. For women of chilbearing age: By signing below I indicate that I am NOT pregnant. Furthermore, I agree
to keep my doctor informed if I become pregnant during the course of the treatment.
13. I agree that the Courts in Pune will have exclusive jurisdiction in case of any dispute or claim arising out of
the performance of the procedure/s.
14. I also declare the following - (Tick the option appropriate)

Conditions which may affect blood circulation and/or ability to fight infection YES_ NO_
History of epilepsy, seizures, fainting or narcolepsy. YES_ NO_
Pacemaker or major heart problems. YES_ NO_
History of hemophilia or excessive bleeding or blood dyscrasias. YES_ NO_
Excessive scars/Keloids YES_ NO_
Organ transplant YES_ NO_
Pregnant/nursing YES_ NO_
Undergoing chemotherapy YES_ NO_
On anticoagulants or other medications that thin the blood or prevent clotting YES_ NO_
History of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals or other
sensitivities related to body art procedures. (Specify when applicable) YES_ NO_
History of any similar or other procedure in the past and complication, if any YES_ NO_
Viral infections and/or diseases or active breakout (HSV ,HIV/AIDS, Hepatitis) YES_ NO_
Signed on __ /__ /____
at __:__ AM /PM Signature/thumb impression Name/ relationship with the patient

Patient 

Surrogate/Guardian

(if applicable and why is

patient unable to give
consent#)

**Witness

Doctor/ Lead Surgeon

*Right hand the males & left hand for Female  #Only if patient is a minor or unable to give consent **In case of
thumb impression only

For Office Use-

Patient Initials _______

I, Dr. _____________________________, have explained the nature, potential risks and complications intended
benefits, expected post-procedure course and possible alternatives to the planned procedure, to the patient/patient
Representative. I am confident he/she has understood the information fully as described in this document.

Consent obtained by_________________________ Signature_____________________________Date:

Patient Initials _______