Spray Tan Consent Form

Name*

Phone*

Date of birth*

Date

Address

Email

example@example.com

How did you hear of us?

Are you over 18 ? *

YesNo

If no, state age:

& parental consent will be required.

Have you ever received a spray tan or applied a sunless tanner before?*

YesNo

Any allergic reactions to Dihydroxyacetone (DHA)?*

YesNo

Do you have any allergies?*

YesNo

If yes, please list:

Do you have eczema or psoriasis ?*

YesNo

Do you have asthma or any other respiratory conditions ?*

YesNo

If yes, please list:

Do you have any other skin/health conditions ?*

YesNo

If yes, please list

Are you pregnant ?*

YesNoI Don't know

Are you breastfeeding ?

YesNo

If yes, to the 2 questions above, do you have doctors permission?

YesNo

Are you currently burnt from*

Natural SunTanning BedsNoOther

Are you on hormone replacement medications?*

YesNo

Any sensitivity to fragrance or smell?*

YesNo

Is there anything else we should know about?

What's your skin tone?*

What's your skin type? (select all that apply)*

How does your skin react with the sun?*

Always burn, never tanBurn then tanAlways tan, never burn

What jewelry best matches your skin tone?*

SilverGoldBoth, Silver and Gold

What kind of tan are you looking for?*

NaturalDramatic

On a scale of 1-10 how dark do you want your tan?

• DHA is listed in the Food, Drug & Cosmetic Act (FD&C Act) as a colour additive for use in imparting colour to the human body. However, it is used in cosmetics – including sunless “tanning”

• DHA reacts with the skin’s amino acids resulting in a “tan” similar looking to sun/bed tanning. The darker you tan naturally, the darker you tan with a spray tan.

• Be advised there may be a small percentage of individuals whose skin does not react favourably to spray tanning. Some medications such as birth control pills, hormone replacement medications, or antibiotics may alter your tan. Please consult with your technician if you have any questions.

•All ingredients in the product used in this procedure are intended for cosmetic use with naturally driven ingredients. There are occasions where individuals may be allergic to ingredients in the spray tan solution. If this occurs, shower and discontinue use & contact a physician. You may ask to see the ingredients prior to application.

• Be advised we do NOT advise being sprayed for photographic sessions, modelling assignments, weddings, etc. unless you have had a trial spray tan with us.

WARNING – This product does not contain SPF and does not protect against sunburn. Repeated exposure of unprotected skin may increase the risk of skin aging, skin cancer and other harmful effects to the skin even if you do not burn

I have been given instructions for the proper steps of application, understand the risks involved, and use it at my own risk. I agree to release the owners, operators and manufacturers from any damages that I might incur due to this service. I have been advised to discontinue use if any reaction occurs.*

Yes, I understand

I understand this is a semi-permanent procedure & will fade within 7-10 days depending on my skin type and how well I take care of my tan. To maintain the look achieved, follow the before and after steps; clients require an appointment every 2 weeks to maintain glowing spray tan.*

Yes, I understand

I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.*

Yes, I cited all conditions

“before and after” pictures OR videos for the purpose of documentation, potential advertising and promotional purposes without payment or any other form of compensation. I understand that my image may be edited, copied, exhibited, published or distributed.
Photos, video and audio may be used for the following purposes:
~ Website advertising ~ Marketing purposes ~ Take home manuals
~ Social media platforms ~ Informational presentations ~ Educational purposes I will be consulted about the use of the photographs or video recordings for any other purpose other than those listed above.

I consent to “before and after” pictures AND OR videos for the purpose of documentation, educational, and advertising and promotional purposes.*

Yes, I consentNo, I don't consent

I understand that if I have any concerns, I will address them with my technician. I give permission for my technician to perform the spray tan procedure and will hold Tu Lumia harmless & nameless from any liability that may result from this session. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my service, I will consult my technician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.*

Yes, I have read and understand all of the following

Client Signature: *

Client Printed Name: *

Date*

Date

If under the age of 18 years, you must have a parent or guardian's consent before having a spray tan.

Parent/Guardian Signature:

Parent/Guardian Printed Name:

Date

SPRAY TAN CONSENT FORM

Lets Talk About Your Skin:

Please Read, Sign & Understand The Following: