CHEMICAL PEEL TREATMENT CONSENT FORM

Please fill out the following form to help us understand your treatment profile.

First name

Date of Birth required

Last name

Phone

Email Address

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Have you been hospitalized in the last 12 months?

Yes

If yes, please specify:

Are you currently suffering from a medical condition, illness, or injury?

Yes

If yes, please specify:

Have you had a chemical peel, laser hair removal, microneedling, clear and brilliant laser facial or dermaplaning done within the past 2-3 weeks?

Yes

If yes, please specify:

Do you have a dermatologist diagnosed skin condition?

Yes

If yes, please specify:

Current medications (Dermatologist Rx)

Are you on Accutane/Have you ever been on Accutane?

Yes

Last Accutane use:

Last Retinol use:

Recent Botox/Fillers

If "other", please specify:

CHEMICAL PEEL INFORMED CONSENT: I understand that this is a cosmetic treatment and that no claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol. I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking, and climate. I may or may not experience actual “peeling” with this procedure, as each case is individual. I understand that there is some degree of discomfort, i.e.: stinging, “pin-pricking” sensation, hotness or tightness. I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Jennai Johnson/Skin Divinity by Jennai. I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 15 is mandatory. I have revealed any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels or surgery, types of contraindicated medications such as Accutane, hormone replacement therapy or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment with exception of Accutane which must be discontinued for six months prior. I have not had a peel treatment of any kind within 14 days of my treatment. I understand I cannot have another treatment until recommended by a licensed professional. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by Jennai Johnson/Skin Divinity by Jennai.

I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 15 is mandatory. I have revealed any medical conditions that may effect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels or surgery, types of contraindicated medications such as Accutane, hormone replacement therapy or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment with exception of Accutane which must be discontinued for six months prior. I have not had a peel treatment of any kind within 14 days of my treatment. I understand I cannot have another treatment until recommended by a licensed professional. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by Jennai Johnson.

PHOTO AND VIDEO RELEASE: I give permission for Skin Divinity by Jennai to take photographs and videos of my treatment and results. I understand that these images may be used for marketing and promotional purposes, including social media, website content, and print materials. I understand that my identity will not be disclosed without my explicit consent, and that these images will be used to showcase the quality and effectiveness of the treatments offered by Skin Divinity by Jennai.

BY SIGNING THIS CONSENT FORM, I ACKNOWLEDGE THAT: Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform Jennai Johnson/Skin Divinity by Jennai of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments. I have read and fully understand the terms within the above consent. All my questions have been addressed to my satisfaction. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety.

Your Signature

Today's Date required

Thank you! Information submitted.