Microsoft word - ftciform-lumiere.doc

Client#____________
First Time Check In Form –LUMIERE
Name: ______________________________________ Date: _____________ Birth Date: _______________
Address: ____________________________________ City: ____________________ Zip Code: _________
Home Phone: ________________________________ Work/Cell: ___________________________________
How did you hear about us? __________________________ email: ________________________________
Occupation______________________
Our Device Operator Instructions:
Follow the instructions that are provided to you by our staff member. While there is no risk of overexposing the skin to the light emitted by the device, in order to achieve optimal results it is recommended that the device sessions be limited to one time appropriate session per 24-hour period.
Our Topical Skincare Instructions:
As with all topically applied skincare products, use caution when applying products in the immediate area surrounding eyes. In the event that contact with the eyes occurs, immediately flush with cool water.
Not Intended for Children under the age of Fourteen, Pregnant Women or Individuals with
Light Sensitive Conditions:
Our device is based on technology that has been extensively assessed during clinical studies over 10 years. No significant adverse reactions have been reported using the technology. The safety of this technology for the treatment of children under the age of 14, pregnant women and in patients with light sensitive conditions has not been confirmed. An alternative treatment is recommended for these clients.
Eyewear During the session:
The output of the device is less than the maximum recommended maximum Permissible Exposure to Incoherent Optical Radiation (MPE). Nevertheless it is prudent to ensure that your eyes are closed throughout the session. The frequency of light wave emitted by the device is within the visible light spectrum and poses no threat of retinal burn or any other eye-injury, however, due to the brightness of the light eyewear is provided to enhance your comfort during the session. Some clients that are extremely sensitive to bright light and do not use eyewear may experience slight discomfort including a temporary mild headache.
Photosensitivity:
Photosensitivity can also be caused by: Certain perfumes or plant materials such as St. Johns Wort in contact with the skin; Metabolic disorders such as Parphyria and others light induced rashes, Parphyria is a severe light erythematosus; and Albinism. The following medicines are known to cause temporary photosensitivity: o Chlorpromazine (anti-psychotic), also known as Thorazine, Chlorpromazine HcL, Sonazine.
-Client can be treated if the medicine has not been taken within the last 8 days. o Griseofulvin (anti-Fungal), Also known as Grifulvin V, Fulvicin U/F, Fulvicin P/G, Gris-Peg.
-Client can be treated if the medicine has not been taken within the last 5 days.
o Isotertinoin (Anti-Acne), also known as Accutane and Tretinoin, also known as Retin-A.
-Client can be treated if the medicine has not been taken within the last 5 days

o Tetracycline’s (antibiotic) also known as Helidac, Terra-Cortril, Terramycin, Sumycin,
Tetracycline HcL, Bristacycline, Achromycin V, Actisite, Tetrex, Doxycycline, Ciprofloxacin.
- Client can be treated if the medicine has not been taken within the last 5 days

o Methotrexate (Anti-Arthritis and Anti-Cancer), also known as Methotrexate Sodium, Pf, &
LPF, Mexate-AQ Folex, Trexall.
- Client can be treated if the medicine has not been taken within the last 3 days.
o Amiodarone (Anti-Arrythmic) also known as Amiodarone Codarone X, Pacerone.
-Sessions can be administered after the client has consulted a physician. o Photosensitivity is associated with UV components of sunlight. Although our device only contains red light and no UV we recommend that for extra safety, the precautions listed in
this document are observed.

If you have any concerns that medication that you are currently being prescribed may be one that
results in photosensitivity, we strongly recommend inquiring with your physician.

If you are not satisfied with your treatment results, please let us know!
I have been fully informed and understand the use of the Lumiere System and accept personal
responsibility for my treatments. I understand that ON THE BEACH and its staff are not liable
for any injury to person caused in any way by the use of its services or premises. I am aware
that the results achieved by this treatment may vary from person to person, and I acknowledge
that no promises or guarantees have been made to me as to the results of this treatment.
I further understand that 24 hours notice is required to cancel or change appointment. Failure
to provide sufficient notice may cause a cancellation fee of $50.00 to be charged or 1 pre-paid
treatment to be forfeited. Treatments may only be re-scheduled a maximum of three times.
Treatments are non-transferable and non-refundable.
All sales are final. All sales expire 6 months from sale date. Other restrictions may apply.
I have read, understand and agree to be bound by the information, terms and conditions listed above. WRITE “I have read the above” on the line below.
____________________________________________________________________________
Customer Signature: ________________________________________
Date: ___________
Dear Client: We VALUE your feedback; please feel free to contact Gino with any Comments about your Experience at [email protected].

Source: http://www.onthebeachcenter.com/pdf/FTCIForm-Lumiere.pdf