VIRTUAL 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:

Please submit the following photos:

Photo Guidelines:

Take photos in natural lighting if possible
Use a solid, neutral background
No makeup, filters, or edits
Hair pulled away from the face
Neutral facial expression

These images will be used solely for professional assessment and to monitor your skin’s progress as we continue working together.

Front view of your face

Upload File

Upload supported file (Max 15MB)

Left side of your face

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Right side of your face

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CONSENT FOR TREATMENT: I consent to receive the specified non-invasive treatments from Skin Divinity by Jennai. I understand that these treatments may involve the use of various products and techniques, including but not limited to facials, chemical peels, microdermabrasion, and LED therapy. I acknowledge that no guarantees have been made regarding the results of the treatment. I have been informed about the potential risks and side effects, which may include redness, swelling, and allergic reactions. I agree to follow the pre- and post-treatment instructions provided by my esthetician to minimize the risk of adverse effects. I understand that it is my responsibility to inform the esthetician of any medical conditions, allergies, or medications that may affect the treatment. I also agree to notify the esthetician of any changes to my health status prior to future treatments. I declare the information Ihave provided is accurate and complete.

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:I have read and understood the information provided in this consent form. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily agree to proceed with the treatment and accept the terms and conditions outlined above.

Your Signature

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Thank you! Information submitted.