To gain access to the TBI - Concussion - Seizure - Neuroprotective protocols, you must be a licensed health professional. Please complete the form below to gain access to the protocol.

Note: this protocol is only valid with VALERIS Class IV Laser Therapy Systems.

Name

Full Name and Health Professional Title

First Name

Last Name

Health Professional Title and License #

Cell Phone

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Email

WAIVER

I acknowledge and agree to the following regarding my use of Class IV transcranial photobiomodulation therapy (tPBM): 1. OFF-LABEL USE ACKNOWLEDGMENT I understand that the use of Class IV laser devices for transcranial photobiomodulation therapy represents an offlabel application. While research demonstrates therapeutic benefits, this application has not been specifically FDAapproved for transcranial use. 2. PROFESSIONAL RESPONSIBILITY I accept full professional responsibility for: • Patient selection and screening • Treatment protocols and parameters • Safety procedures and precautions • Clinical outcomes • Any adverse events or complications • Documentation and informed consent • Proper device operation and maintenance 3. SCOPE OF PRACTICE I hereby confirm that: • I am a licensed medical professional with appropriate credentials • Transcranial PBMT falls within my professional scope of practice • I have received adequate training in Class IV laser operation and safety • I understand the mechanisms, risks, and contraindications of high-powered NILT 4. SAFETY PROTOCOLS I agree to implement proper safety measures including but not limited to: • Use of appropriate eye protection for staff and patients • Following established fluence and power density parameters • Proper screening for contraindications 5. INFORMED CONSENT I will obtain proper informed consent from patients, explicitly discussing: • The off-label nature of the treatment • Potential risks and benefits • Alternative treatment options • Expected outcomes and limitations 6. DOCUMENTATION I agree to maintain detailed clinical records including: • Treatment parameters used • Patient responses and outcomes • Any adverse events • Follow-up assessments By completing this form, I acknowledge my understanding and acceptance of all above terms and conditions regarding my use and delegation of Class IV transcranial PBM.

Comments

Informed Consent Example**

The following example waiver form is provided solely for informational purposes. It does not constitute legal advice, nor does it guarantee legal efficacy or compliance with local regulations.

Anyone intending to use, modify, or rely on this waiver should seek advice from a qualified attorney before implementation. The provider accepts no responsibility for actions taken based on this example or for legal outcomes resulting from its use.

Photobiomodulation Expert + VALERIS Class IV Therapy Lasers

Contact

vkrossin@gmail.com
(352) 459-9917

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Photobiomodulation Expert + VALERIS Class IV Therapy Lasers

Contact

vkrossin@gmail.com(352) 459-9917

vkrossin@gmail.com
(352) 459-9917