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Vacial Informed Consent

The information provided in this informed consent should be followed by all patients receiving a Vacial Treatment. You will be asked to sign this form acknowledging that you have read and understood all of the information presented.

 

CLIENTS WHO SHOULD NOT BE TREATED: clients with active cold sores or warts, skin with open wounds, sunburn, excessively sensitive skin, dermatitis or inflammatory rosacea in the area to be treated. Inform the esthetician if you have any history of herpes simplex. You should also not have a Vacial if you have a history of allergies, rashes, or other skin reactions, or may be sensitive to any of the components of this treatment. Most Vacials should not be performed on clients with an allergy to salicylates (i.e., aspirin). This Vacial is also not recommended if you have taken Accutane within the past year, or received chemotherapy or radiation therapy and should not be administered to pregnant or breastfeeding (lactating) women.

 

ONE WEEK BEFORE YOUR VACIAL: Avoid these products and/or procedures for one entire week prior to your vacial: *

 

Electrolysis

Waxing

Depilatory Creams

Laser Hair Removal

Sun Exposure

retina, Renova, Differin (Adapalene 0.1%), Tazorac or any product containing Retinol

 

TWO TO THREE DAYS BEFORE YOUR VACIAL: Stop using:

Any products containing AHA or BHA, or benzyl peroxide

Any exfoliating products that may be drying or irritating

 

AFTER YOUR VACIAL: It is crucial to the health of your skin and the success of your vacial that these guidelines be followed:

 

1. Avoid direct sunlight for at least 1 week.

2. Avoid strenuous exercise for 24 hours.

5. When washing your skin, do not scrub. Use a gentle cleanser.

6. Apply a light moisturizer as needed.

7. Do not have any other vacial treatments for a least one week after your vacial.

8. You may resume the regular use of Retin-A, alpha-hydroxy acid (AHA), or bleaching creams a week after Vacial.

 

 

The nature and purpose of the treatment have been explained to me. I have read and understand this agreement in its entirety. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. Alternative methods of treatment and their risks and benefits have been explained to me and I understand that I have the right to refuse treatment.

 

I release The Naked Peach Waxing Boutique and all staff, from any and all liability. This release would include todays visit and any and all future visits at salon for this Vacial service.

 




First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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