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Laser Therapy Waiver and Release Mobile App

This Laser Therapy Waiver and Release mobile app is used by a health care physician or nurse practitioner to provide information on laser therapy and to capture patient information for informed consent.

The app informs the patient of short term effects, possible permanent effects of light treatment, potential discomfort, the effect of ultraviolet light, and more. Also captures the patient's signature to indicate the patient agrees to the information provided on the procedure and that the risks have been reviewed.

All liability waiver forms are securely saved in the GoCanvas Cloud and can be emailed or printed as a PDF if you need to share the release form with others.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Laser Therapy Waiver and Release Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    I understand that a LASER is being used for my treatment.

  • Ico statictext

    Short term effects: I understand that there are multiple short term effects that may occur, inclu...

  • Ico statictext

    Possible permanent effects: I understand that although most side effects are short term and resol...

  • Ico statictext

    Discomfort associated with procedure: I understand that the laser functions by heating up its tar...

  • Ico statictext

    Effects of UV: I understand that sun exposure, tanning beds, sunless tanning lotions, and tanning...

  • Ico statictext

    People excluded from therapy: I understand that certain patients should not have laser treatment.

  • Ico statictext

    Need for multiple treatments: I understand that some conditions being treated by the laser may re...

  • Ico statictext

    Tattoo/permanent makeup: If there are any tattoos or permanent makeup in the area, there is a pos...

  • Ico statictext

    Photographs: I understand photos or video of my treatment may be taken.

  • Ico statictext

    For laser vein treatment: I understand that this procedure involves a laser to coagulate the vess...

  • Ico statictext

    I agree to wear proper eyewear.

  • Ico statictext

    I understand that this procedure is elective & there are other options for treatment including no...

  • Ico statictext

    I understand that my insurance company will not cover the cost of laser therapy, and I am respons...

  • Ico statictext

    (DOCTOR) has explained the nature and purpose of the laser treatment, including any risks and pos...

  • Ico statictext

    I further understand that results CANNOT be guaranteed.

  • Ico textbox

    Name

  • Ico date

    Date

  • Ico signature

    Patient Signature (Parent or guardian if patient is under 18)

  • Ico textbox

    If signed by other than patient, indicate relationship

  • Ico signature

    Physician/Nurse Practitioner Signature

  • ...and More!

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