Skin Type/Consent Form

Skin Type/Consent Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Home or Work Phone
Please enter a valid phone number.
Email
example@example.com
How did you hear about us?
D.O.B.

MonthDayYear
Date
Please answer the following questions:

When exposed to UV radiation from sunlight or tanning beds:

	Yes	No
Do you eventually develop a tan?
Do you always sunburn without developing a tan?

What is the natural color of your un-tanned SKIN?

Reddish-WhiteWhite-BeigeBeigeLight Brown, OliveBrownBlack
What is your natural HAIR color?

Red, Light BlondeBlonde, Light BrownBrownDark BrownBrownish-BlackBlack
What is your EYE color?

Light Blue, Light Green, Light GreyBlue, Green, GreyDark Grey, Light Brown, HazelBrownDark Brown
How many FRECKLES do you have?

NoneFewSomeMany

Which best describes your GENETIC heritage?

	Mother	Father
Caucasian, Celtic (English/Irish)
Caucasian, Lighter-Skinned European
Caucasian, Darker-Skinned European
Caucasian, Mediterranean
Middle-Eastern, Indian, Hispanic, Asian
Aborigine, African, African-American

Which best describes your SUNBURN potential?

Always Sunburns Without TanningUsually Sunburns/Can Tan a LittleOccasionally Sunburns/Tans ModeratelySeldom Sunburns/Tans EasilyRarely Sunburns/Develops Dark TanNever Sunburns
Which best describes your TANNING potential?

Never TansCan Develop a Light TanCan Develop a Moderate TanCan Develop a Dark TanCan Develop a Very Dark Tan
When is the last time you have tanned or been in the sun?

MonthDayYear
Date
Are you now sunburned? (If yes, do not tan today)

YesNo
Are there areas of your body that are not now tanned?

YesNo
How would you describe your level of acquired tan at this time?

No TanLight TanModerate TanDark Tan
Have you ever been advised by a physician to stay out of the sun?

YesNo
Why?
Are you taking any medications or using a cosmetic product that could cause photosensitivity?

YesNo
Please list:
Are you pregnant or suspect that you may be pregnant?

YesNo
Do you have systemic lupus erythematosus?

YesNo
Do you have rosacea?

YesNo
Do you have psoriasis?

YesNo
Do you have seasonal affective disorder?

YesNo
Have you ever received medical treatment for a diagnosis skin cancer?

YesNo
Please explain:
Client Release & Consent Form
We reserve the right to refuse service to anyone at any time. Please read the following information and acknowledge that you understand & accept all provisions by signing below.

1) We recommend sensible, moderate, and responsible exposure to UV radiation.

2) Please follow all instructions regarding the operation of all tanning equipment. The proper procedure to follow in the tanning room has been clearly explained by the tanning consultant. Please feel free to ask any questions or to voice any concerns that you might have before starting to tan. Our tanning rooms are reserved for the undersigned individual only (1 tanner per room).

-If you do not develop a tan in the sun, you are unlikely to tan from the use of the tanning devices at the Elite Beach Tanning Co.. Danger-ultraviolet radiation-

3) Avoid Overexposure. As with natural sunlight, overexposure can cause eye, skin injury and allergic reactions. Repeated overexposure to UVR may cause photo aging of the skin, dryness, wrinkling, and (sometimes-fatal) non-melanoma skin cancer. We recommend that you do not tan outdoors on days you are tanning indoors, do not tan if you have a sunburn, seek medical care if you suffer a severe, painful, and blistering, sunburn and that you tan no more often that every other day.

4) Wear Protective Eyewear. FDA law requires you to wear protective eyewear & Failure to wear protective eyewear may result in severe burns or long term injury to the eyes. We recommend that you remove contact lenses before tanning. Show proof of eyewear prior to your tanning session.

I have read the contents of this client release and informed consent form carefully and state that I am not aware of any medical condition or other reason that would prohibit me from tanning. I understand that while I will not be allowed to exceed the maximum allowable time posted on the tanning bed I will use, my skin type/subtype, tanning history and level of existing base tan may allow me to tan longer than the posted schedule and I do so at my own risk. I have been given adequate instructions regarding the proper use of the tanning equipment I will use, understand the risks involved and I do so at my own risk. I hereby agree to release the owners, operators, manufacturers, distributors, leasing agents, and any governmental agency from any damages that I might incur due to the use of this tanning facility.

All minute packages expire 1 year from date of purchase, unless otherwise specified. No sharing, splitting, or transferring packages, or memberships. There is a $25 fee on all returned checks. All sales are final and non-refundable. For insurance purposes children can not be left unattended.
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Parent/Guardian Consent
I hereby give my permission as parent or guardian of First Name Last Namewho is Age years of age and is my Relationship to Patient to tan at the Elite Beach Tanning Co.. I have read and understand this client release and informed consent form and agree to accept all of its provisions.
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Skin Type/Consent Form

Client Release & Consent Form

Parent/Guardian Consent