Lucia N°03 Informed Consent Form

At Fractalize & Rise and Be Well, and in other light salons around the world, the Lucia N°03

Hypnagogic light experience is not specifically intended to cure, treat, prevent or heal any

disease, injury, or illness. I understand that if I have a health problem, or think I may have a

health problem, I will be referred to a licensed professional for further assistance upon my

request.

I understand the services provided by light attendants at Fractalize & Rise and Be Well,

may cause certain side effects such as:

- fluttering of the eyes

- feeling like you have transcended or left your body

- visions, symbols, and/or emotions may arise

- in rare cases (including undiagnosed epilepsy) a seizure may occur

I understand that these effects may arise through no fault of light guide Ryan Marie Potter. If I have any concerns about any of these possible side effects, I will keep light attendants fully advised about my concerns so the intervention may be terminated if necessary

or revised to minimize any discomfort. I understand that I am fully responsible for my own

decisions and fully aware of the potential side effects.

I understand that using the light machine is not advised if the client:

- is under 18 years of age

- is pregnant

- has a history of epilepsy or seizures

- has a history of severe anxiety, or other psychosis

- is under the influence of any drugs or other mind-altering substances

I understand the above statements and it is my choice to participate in this experience.

Name of Client: __________________________

Email address: _________________________________________

Signature: ___________________________________ Date:____________________

Emergency contact info: ___________________________