Farrah Rose GLO Lounge Release Form

Client Name*

First NameLast Name

Client Date of Birth*

Date

Client Email*

example@example.com

Client Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you age 18 or under?*

YesNo

Parent/Guardian Name (for 18 years old and under)*

First NameLast Name

Parent/Guardian Phone Number*

Please enter a valid phone number.

Parent/Guardian Email Address*

example@example.com

What membership/service will you be utilizing?

Have you used any indoor tanning beds within 6 months?*

YesNo

Do you have any known food or drug allergies?*

YesNo

What type of allergies?*

Are you currently pregnant or breast feeding?*

YesNo

Do you have any respiratory ailment?*

YesNo

Do you have any cardiovascular ailment?*

YesNo

Do you have high-blood pressure or hypertension?*

YesNo

Have you had any surgery within 6 months?*

YesNo

Do you have any history of skin cancer, including but not limited to melanoma?*

YesNo

Did you undergo any skin treatment inside a clinic before?*

YesNo

If yes, please tell us what kind of treatment and where did it happen or what is the name of the beauty clinic?*

Are you currently taking any medications?*

YesNo

MEDICATIONS:

ACE INHIBITORS	CONTRACEPTIVES
ANTIDEPRESSANTS	DIRUETICS
ANTIHISTAMINES	HYPOGLYCEMIC SULFONYLUREAS
ANTIMICROBIALS	NSAIDS (Non-Steroidal Anti-Inflammatory Drugs)
ANTIPARASTICS	PHENOTHIAZINES
ANTIPSYCHOTICS	PSORALENS
CANCER CHEMOTHERAPY	SUNSCREENS
CARDIOVASCULARS

I acknowledge that if I am taking ANY of the following medications, it is recommended by Farrah Rose LLC that I consult with my doctor, pharmacist, or physician prior to any UV exposure due to the risk of having a photosensitive reaction.*

I agree to the above statement and I believe to the best of my knowledge that the information contained is fully understood.

DANGER - ULTRAVIOLET RADIATION

- Follow Instructions

- Avoid overexposure. With natural sunlight, overexposure can cause eye and skin energy and allergic reactions.

REPEATED EXPOSURE MAY CAUSE PREMATURE AGING OF THE SKIN AND SKIN CANCER

- Wear protective eye wear.

FAILURE TO USE PROTECTIVE EYEWEAR MAY RESULT IN SEVERE BURNS OR LONG TERM INJURY TO THE EYES

- Medications or cosmetics may increase your sensitivity to the ultraviolet raditiation. Consult a physician before using any sunlamp or tanning equipment if you are using medications or have a history of skin problem or believe to yourself to be especially sensitive to sunlight.

- If you do not tan in the sun, you are unlikely to tan from the use of this product.

- Consumers should report to the agency any injury for which medical attention is sought or obtained resulting from the use of registered tanning equipment. This report should be made within 5 working days after the occurance.

SUNLESS TANNING WAIVER

DHA is listed in the Food, Drug and Cosmetic Act (FD&C Act) as a color additive for use in imparting color to the human body. However, its use in cosmetics – including sunless “tanning” products – is restricted to external application. According to CFR, “externally applied” cosmetics are those “applied only to external parts of the body and not to the lips or any body surface covered by mucous membrane” (21 CFR 70.3v).

DHA reacts with the skin’s amino acids resulting in a “tan” similar looking to that of the sun. The darker you can tan naturally, the darker you can tan with a spray tan. Like most cosmetics, avoid exposure to the eyes, lips, and other parts
of the body covered with a mucous membrane. This should be accomplished by the following the staff’s breathing instructions as to avoid inhaling or ingesting the sunless product.

Your spray tan should last 5-10 days, depending on your skin type and how well you take care of your sunless tan. It’s very important to keep your skin moisturized after your spray tan, avoiding long baths or showers and hot tubs. Salt
water exposure or a chlorinated pool can also shorten your spray tan.

I understand that the results of airbrush tanning do vary and there’s no guarantee of specific results that are offered or implied.

I hearby release Farrah Rose LLC as well as the spray tan technician and hold them harmless from any liability involved in the use of or arising during the tanning process or there after.

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

Farrah Rose LLC provides protective barrier cream and coverings to use at your descretion for best results and safety.

RED LIGHT THERAPY WAIVER

LED light therapy is a safe, relatively risk-free treatment.

It’s rare to experience side effects from LED light therapy. If side effects do occur, they may include:

Increased inflammation
Rash
Redness
Pain
If you have any concerns following your treatment please contact your practitioner.

Always wear protective eyewear. Failure to wear protective eyewear may result in
burns or long-term injury to the eyes.

You should prepare your skin for your session prior to your arrival. For optimal
results, skin should be free of deodorant, make up, fragrances, and oils. Remove jewelry.

Certain Medications or cosmetics may increase your sensitivity to the red and/or
LED light.

If you are pregnant or nursing we suggest consulting your physician
before using LED light therapy.

For optimal results recommended therapy schedules are 3-5 days per week, for 4-6 weeks. After the initial treatment schedule it is recommended to continue 1-2 days per week.

After treatments sit up slowly to prevent dizziness.

LED light therapy is noninvasive, so no recovery time is required. You should be able to continue with your everyday activities once your treatment is over.

You may start to see minor results after your first session. Results will be more dramatic and noticeable once you’ve finished all of your treatments.

Even after you’ve achieved the recommended number of sessions, your results aren’t permanent.

I understand that LED light therapy is not intended to take place of medical care or medications.

To my knowledge, I have no medical condition which would prohibit me from using LED light therapy.

I acknowledge that the results of LED light therapy do vary, and that no guarantees of specific results are offered or implied. Farrah Rose LLC will not refund or credit any amount of money because of a client’s unhappiness with their final results.

I have been I have been given adequate instructions for the proper use of the equipment, understand the risks involved, and use it at my own risk.

I hereby agree to release the owners, operators and manufacturers from any damages that I might incur due to the use of this facility.

I have reviewed and completely understand all of the information at
www.FarrahRoseBeauty.com, including this form.

GENERAL WAIVER

I understand the risk of indoor and/or sunless spray tanning to my skin and overall health and that wearing protective eyewear while tanning in this facility is a requirement.

I understand that this is a 24/7 access tanning facility and choose to tan and utilize Red Light at my own risk. I understand that at any given time I may be the only person inside the building. I hereby abslove Farrah Rose LLC of any liabilities, claims, or lawsuits for any injuries or claims obtained while on the premise.

I understand that tanning is not recommended for those with certain health concerns or conditions, including those with past/present respitory or cardiac ailments and those that are pregnant or breastfeeding. I understand it is my responsibility to consult with my pharmacist, provider, or physician for any health or medication conerns with indoor tanning or spray tanning.

I hereby absolve Farrah Rose LLC of any liabilities, claims, and lawsuit for I was forewarned of the risk of indoor tanning or sunless spray tanning to my skin and overall health.

Farrah Rose LLC 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.

Any cancellation or reschedule made less than a 24 hour timeframe will result in a cancellation fee for any single service. The amount of the fee will be equal to 70% of the reserved services or $25, whichever is more. If you are more than 15 minutes late for your service, we may not be able to accommodate you. In this case, the same cancellation fee will apply. We will do our very best to reschedule your service for another time that is convenient to you. We require a credit card to hold your appointment. Cancellation fees will be charged to your card on file. In the event of a true, unavoidable emergency, all or part of your cancellation fee may be applied to future services.

I understand that the Farrah Rose Team will make a recommendation on my tanning times and regimens based on the Skin Type Chart (Fitzpatrick Scale).

YesNo

Client Signature*

Date Signed*

Date

If you are completing this under the age of 18, a separate consent form will be sent to your legal guardian's email for signature and official completion of consent.

Farrah Rose GLO Lounge Release Form

Consent