Airbrush Consultation Form

Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / 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?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Do you have any skin or pigmentation disorders?*

YesNo
Is your skin hypersensitive?

YesNo
Do you have allergies? List below
Do you have any open cuts/wounds/rashes?*

YesNo
Have you recently had any body piercings or tattoos?

YesNo
Do you wear contact lenses?

YesNo
Is the tan for a special occasion?

YesNo
If yes, what occasion?
Have you had an airbrush tan or used tanning products before?

YesNo
If yes, how was your experience?

PositiveNegative
Do you burn or tan in the sun?

BurnTanBoth
Under the age of 18?*

YesNo
Parent/Guardian Signature
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
Date

MonthDayYear
Date
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