Tanning Registration and Consent Form

Tanning Registration and Consent Form
PLEASE NOTE: You have to be 18 to tan without a parent consent. If you are under 18 you will be required to fill out an additional form with Parent or Guardian present.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Parent/Guardian Name (if you are under 18 years old )You will also need to come in with Parent/Guardian in order to set up any tanning packages

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
IF YES, for what reason
YesNo
YesNo
IF YES, for what reason
YesNo
YesNo
YesNo
SKIN TYPING

Please fill this out to determine you natural skin type
Lt Blue, Gray, GreenBlue, Gray, GreenBlueDark BrownBrownish Black
Sandy/RedBlondeChestnut/Dk BrownDark BrownBlack
ReddishVery PalePale with a Beige TintLt BrownDrk Brown
ManySeveralFewIncidentalNone
Painful Redness, Blistering, PeelingBlistering followed by peelingBurn sometimes followed by peelingRarely BurnsNever Burns
Hardly or Not at AllLight Color TanReasonable TanTan Very EasilyTurn Dark Brown Quickly
NeverSeldomSometimesOftenAlways
Very SensitiveSensitiveNormalVery ResistantNever Had a Problem
More than 3 months ago2-3 months ago1-2 months agoLess than a month agoLess than 2 weeks ago
NeverHardly everSometimesOftenAlways
Skin Type Score
0-7 I8-16 II17-25 III25-30 IVOver 30 V
Consent
I understand the risk of indoor tanning to my skin and overall health. Wearing protective eyewear is a requirement. I understand that the employees here are trained and skilled to do their tasks and I should comply with the Tanning Salons' policy and procedure. The company will require me to wear protective glasses during the procedure. I hereby absolve the tanning salon of any liabilities, claims, any lawsuit from my side for I was forewarned of the risk of indoor tanning to my skin and overall health. The company also affirmed the harmful effects of overexposure to ultraviolet radiation emitted by the tanning device may cause skin burns, premature skin aging, melanoma, and skin cancer.
Signature*

Clear
Date*

MonthDayYear
Date
OHIO STATE COSMETOLOGY & BARBER BOARD

TANNING CONSENT FORM
Signature on the consent form below is an indication that I have read and understand the risks factors of ultraviolet radiation and overexposure contained on the "Tanning Risks and Important Information" sheet provided. I understand that certain medical conditions and/or medications may cause a photosensitivity of the skin. I further understand that failure to wear protective cyewear may result in severe burns or injury to the eyes. It is also my understanding that a certified tanning operator must perform a skin typing assessment prior to tanning to determine an individualized exposure schedule.

Notice: According to the Centers for Disease Control (CDC), indoor tanning exposes users to UV-A and UV-B radiation and has been linked with skin cancers including melanoma (the deadliest type of skin cancer), squamous cell, and basal cell carcinoma, and cancers of the eye (ocular melanoma Indoor tanning is particularly dangerous for younger users; people who begin indoor tanning during adolescence or early adulthood have a higher risk of getting melanoma.

The product is contraindicated for use on persons under the age of 18 years; the product must not be used if skin lesions, or open wounds are present; the product should not be used on people who have had skin cancer or a family history of skin cancer; and people repeatedly exposed to UV radiation should be regularly evaluated for skin cancer. A contraindication means that the product is not indicated for use on persons under the age of 18 years of age.
The following must be completed for any person 18 years of age or older, who intends to use sun lamp tanning services:
This statement must be completed and signed to indicate an understanding of the risks associated with the use of indoor sunlamp products.
YesNo
I have read and acknowledge the risk factors associated with the use of indoor sunlamp products.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Tanning Registration and Consent Form

SKIN TYPING

Consent

OHIO STATE COSMETOLOGY & BARBER BOARD