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: *
Laser Hair Removal
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.