ORTHOLAZER ORTHOPEDIC LASER CENTER
Consent to Treat with MLS Laser Therapy

I hereby authorize and consent to receive treatment using the Class IV MLS Therapy Laser at OrthoLazer Orthopedic Laser Center. I understand that this modality utilizes a non-invasive, painless, and invisible beam of light designed to stimulate cellular activity and promote tissue healing. 

I acknowledge that a valid referral from a qualified healthcare provider, such as my primary doctor, orthopedist or nurse practitioner, is required before I begin treatment.

Benefits of MLS® Laser Therapy

MLS Laser Therapy uses specific wavelengths of light to help reduce pain, decrease inflammation, and promote faster healing of soft tissues and joints. Many patients experience improved comfort and mobility following treatment.

Medical Considerations and Risks

I understand that while MLS® Laser Therapy is generally considered safe, it should not be used in any of the following situations or ways: 

• Over the uterus during any stage of pregnancy.
• On a pregnant patient that is less than 16 weeks pregnant.
• On patients with a known hypersensitivity or adverse reaction MLS® Laser Therapy.
• On patients with active blood-borne malignancies including leukemia, lymphoma, or multiple myeloma.
• Directly over solid malignant tumors. 
• Directly into the eye or periocular area.

MLS® Laser Therapy should also not be used in the following ways: 

I also understand that there are other medical conditions that may require permission from my doctor or healthcare provider before treatment. I have shared all the health issues I know about, and I know that not sharing them could affect how safe or helpful the treatment is. 

Patients taking anticoagulants (blood thinners), those with a known bleeding disorder (hemorrhagic diathesis), or those taking photosensitizing medications should monitor themselves for any skin reactions after receiving MLS® Laser Therapy. 

Pregnant patients must obtain written approval from their OB/GYN prior to beginning therapy and provide a copy of such written approval to OrthoLazer.

Alternative Treatments to MLS® Laser Therapy

Alternative treatments to MLS Laser Therapy may include rest, ice or heat application, physical therapy, medications such as anti-inflammatories or pain relievers, steroid injections, or other medical or surgical interventions. These options can be discussed with your provider to determine the best treatment plan for your condition.

Treatment Expectations

I understand that, like with any medical treatment, results can be different for each person depending on the unique condition being treated. Many people feel better after MLS Laser Therapy, but there is no promise that all symptoms will go away. If the therapy doesn’t work, I might need other treatments or to see a different doctor.

I understand that upon completion of treatment at OrthoLazer, no further medical evaluation or management will be provided by OrthoLazer staff or affiliated providers. It is my responsibility to follow up with my primary care physician and/or relevant specialist(s) for continued evaluation and care if symptoms persist or worsen.

Safety Precautions

I understand that protective eyewear must always be worn during MLS Laser Therapy to protect my eyes from potential exposure to laser light. I also understand that I should not apply ice to the treated area for at least eight (8) hours after each session, as this may interfere with the healing and circulation benefits provided by the laser treatment.

Communication and Follow-Up

I have been informed that OrthoLazer staff are available to answer any questions I, or my referring healthcare providers, may have regarding my care. I authorize OrthoLazer to share treatment progress notes with my referring provider upon request.

Financial Policy

Payment for the entire treatment plan is due at the time of the first visit. I understand MLS® Laser Therapy is not covered by my insurance and I am responsible for paying for MLS® Laser Therapy. Additional pricing information is available upon request. 

No refunds or partial credits will be issued for missed or incomplete sessions in a prepaid treatment plan. All sales are final. Purchased laser therapy treatments (used or unused) are nonrefundable. There are no returns or cancellations of laser therapy sessions already purchased. Laser therapy treatment plans expire after 12-months. 

Accepted forms of payment include cash, MasterCard, Visa, Discover, and American Express. OrthoLazer does not bill insurance. A billing summary of these self-pay services may be provided upon request by myself or my authorized representative of record. 

Cancellation and No-Show Policy

Appointments must be canceled or rescheduled at least 24 hours in advance. A grace exception will be given for the first late cancellation or missed appointment. For any subsequent occurrences, a $20 fee will be applied before further appointments can be scheduled. This policy is in place to ensure timely access to care for all patients and may vary at individual centers. 

Ownership Disclosure

Certain providers affiliated with OrthoLazer Orthopedic Laser Center, including (insert list of OLC investor providers), maintain a financial ownership interest in this facility. This ownership may allow them greater influence over the quality and delivery of care provided. Patients are under no obligation to receive treatment at OrthoLazer and retain the right to seek care at a facility of their choice. Choosing an alternative treatment facility will not affect the care I receive from my OrthoLazer provider. 

Acknowledgment and Consent

I, the undersigned patient or authorized legal representative, acknowledge that I have read and fully understand this Consent to Treat form. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. 

I understand the instructions that have been provided to me by OrthoLazer, and acknowledge I was presented with the opportunity to ask any and all follow up questions related to the therapy post-treatment care and expectations. I further understand the risk of treatment and the risks of not following the required safety precautions.

 I also understand that MLS® Laser Therapy is not effective in 100% of the patients. I voluntarily consent to receive MLS® Laser Therapy treatment at OrthoLazer Orthopedic Laser Center by OrthoLazer. I further understand MLS® Laser Therapy is not covered by insurance and I will be responsible for paying 100% of the costs of all treatment sessions. 

Patient or Legal Representative Signature: ___________________________

 

Printed Name: _________________________________________________

 

Date: ___________________