Client Intake Form

1

Name (First & Last)

2

Address

3

Email

example@example.com

4

Phone

5

Date of Birth (MM/DD/YYY)

6

Date of Service

Date

7

How did you hear about us?

8

Do you have any Skin Concerns? (Yes/No. If yes, explain)

9

Are you currently taking any Medications? (Yes/No. If yes, please list)

10

Do you have any known allergies? (Yes/No. If yes, please list)

11

Are you currently breastfeeding or pregnant? (Yes/No)

12

Do you have any open cuts, wounds, or fresh tattoos or piercings? (Yes/No)

13

Did you shave and or exfoliate within the last 24 hrs? (Yes/No)

14

Are there any products on your skin? (Yes/No)

15

*Which best describes your skin type? (Fair, medium, dark)* This field is required.

*Fair,Medium,Dark

16

*What level of tan would you like to achieve? (Light, Natural, Bold)* This field is required.

*Fair,Medium,Dark

17

Do you give permission to use photos of your tan for marketing? (Yes/No)

18

Spray Tanning by use of DHA (active ingredient) is generally considered to be safe and has been FDA approved ONLY if you follow guidelines to protect mucous membranes. You may request measures to protect your eyes and mucous membranes and prevent inhalation. All ingredients used in this service are intended for cosmetic use and generally regarded as safe (ingredient list is available upon request Individuals may be allergic to one or more ingredients in the spray tan solution. Spray Tanning does not provide protection from the sun and does not contain any SPF.

19

Signature

20

Today's Date

Date