Waxing Informed Consent Form

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This form must be completed prior to your first facial at Poplar Creek Spa.

Email *

First name *

Last name *

Name you go by *

Do you use any of the following products, or have you in the past?

Accutaine
*

Yes

When? *

Alpha hydroxy acid (AHA) or glycolic products
*

Yes

When? *

Retin-A, Renova
*

Yes

When? *

Any other skin thinning products and/or drugs
*

Yes

If yes, please list. If no, write n/a. *

Do you have diabetes?
*

Yes

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?
*

Yes

Do you use a tanning bed?
*

Yes

What products do you use regularly on your skin? *

Have you ever been treated for cancer? *

Yes

If yes, when and what types of treatments were used? If no, write n/a. *

Please list any other illnesses/conditions for which you are currently being treated by a medical professional. *

I understand and agree to the following:

I acknowledge that all the information provided by me is true and correct to the best of my knowledge.

Waxing has potential side effects such as skin removal, redness, swelling, tenderness, etc. It is important that I give accurate answers to the questions above, including all known allergies, prescription drugs, or products I am currently using internally or topically. My aesthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

If I have used Accutane in the past six to 12 months, or Retinol, Retin-A, or Renova in the past week, I may be asked to reschedule my waxing appointment.

If I am currently menstruating, my waxing service may be slightly more painful than usual.

I have read and understand the post-treatment home care instructions my aesthetician has provided me with. I should follow these recommendations in order to minimize or eliminate possible negative reactions. If I have additional questions or concerns regarding the above information, my treatment, or home care, I will consult my aesthetician immediately.

By signing this form, I am granting permission to my aesthetician to perform the waxing procedure we have discussed. I will hold my aesthetician and Poplar Creek Spa, LLC harmless from any liability that may result from this treatment.

This form constitutes full disclosure, and supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above and that I have had sufficient opportunity to discuss any questions or concerns. I understand the procedure and accept the risks. I do not hold my aesthetician or Poplar Creek Spa, LLC responsible for any conditions that were present but not disclosed at the time of this procedure, which may be affected by the procedure performed today.

Completion of this form serves as my electronic signature.

Required

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A copy of your responses will be emailed to the address you provided.

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