Airbrush Consultation Form

Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Phone Number
Have you had any surgery or medical treatment in the last 12 months? If yes, list below
Do you suffer with any respiratory problems? *

Yes No
Are you pregnant or breastfeeding? *

Yes No
Do you have any skin or pigmentation disorders? *

Yes No
Is your skin hypersensitive?

Yes No
Do you have allergies? List below
Do you have any open cuts/wounds/rashes? *

Yes No
Have you recently had any body piercings or tattoos?

Yes No
Do you wear contact lenses?

Yes No
Is the tan for a special occasion?

Yes No
If yes, what occasion?
Have you had an airbrush tan or used tanning products before?

Yes No
If yes, how was your experience?

Positive Negative
Do you burn or tan in the sun?

Burn Tan Both
Under the age of 18? *

Yes No
Parent/Guardian Signature

Clear
Disclaimer: I declare that I have read and understood and answered the questions to the best of my knowledge. I have no known medical conditions or allergies that may affect or induce a harmful reaction from a sunless tanning treatment. The information above is for the estheticians records only and will not be misused or passed on to any other third-parties.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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