MLS LASER/ SOFTWAVE THERAPY FORM

WHAT IS THIS FORM FOR?

1

As a new patient, this form helps us understand your current concerns, treatment goals, and overall health history. It allows us to tailor your SoftWave therapy experience so it’s focused, comfortable, and effective from the start.

WHY DO I NEED TO COMPLETE THIS form FULLY?

2

MLS Laser/SoftWave therapy works best when it’s personalized. Completing this form ensures we have the right information to safely and effectively target your treatment area, while also helping you understand what to expect.

HOW LONG DOES IT TAKE
TO COMPLETE?

3

Most patients complete the form in about 5–10 minutes. It’s simple, straightforward, and can be done at your convenience before your visit.

WHAT HAPPENS AFTER I
SUBMIT IT?

4

Once submitted, your responses are reviewed by our team to prepare for your session. No further action is needed—you’ll be ready to begin treatment when you arrive.

MLS Laser Therapy & SoftWave TRT Brighton Campus Chiropractors, L.L.C.  •  Please complete this form to help us tailor the most effective treatment plan for you.
Patient Information
Therapy Candidacy Screening

Please answer all questions so we can determine if you are a suitable candidate for SoftWave TRT / MLS Therapy.

Have you been injected with cortisone this month?
Are you using a cardiac pacemaker?
Do you have cancer or a tumor?
Are you pregnant or do you suspect you may be pregnant?
Are you under 16 years of age?
Did you eat AND hydrate prior to this appointment?
Do you have a history of concussions or loss of consciousness?
Do you have a history of tinnitus?
Medical History
Pain Assessment
No PainUnbearable
1
Previous Treatment
Pain Management
Treatment Goals
Treatment Candidacy
Are you open to trying SoftWave / MLS Therapy as a non-invasive treatment option?
Would you be satisfied if we can reduce your pain by 50% or more and help you reach some of your health goals?
Risks of This Procedure
•SoftWave Therapy may cause some pain and soreness. This is temporary and resolves after a few days.
•MLS Laser Therapy can cause damage to the retinas if proper eye protection is not worn.
•The FDA has labeled this a "Non-Significant Risk" therapy.
Consent for Procedure
I, the undersigned, have been fully informed of SoftWave / MLS Therapy, the use of which has been fully explained to me by my treating physician/staff. I fully understand the nature of this treatment. I confirm that I have been given the opportunity to discuss and clarify any concerns, and that no guarantees have been made to me. Treatment is primarily for pain relief and may offer improvement of function. I also understand that foregoing treatment is not the first option for my condition and an alternate treatment has either already been provided or offered to me.

By signing below, I confirm that all information provided in this form is accurate to the best of my knowledge, and I understand that this data will be used for the purpose of my SoftWave Therapy / MLS Therapy treatment at Brighton Campus Chiropractors, LLC.
Patient Name (Print)
Date
Patient Signature
Parent / Guardian Signature (if applicable)

✓ Form Submitted Successfully

Thank you! Your SoftWave / MLS intake form has been received.
We look forward to seeing you at your appointment.

Brighton Campus Chiropractors, LLC — (585) 272-7340