Farrah Rose GLO Lounge Parent/Guardian Release

Client Name*

First NameLast Name

Parent/Legal Guardian Name*

First NameLast Name

Client Date of Birth*

Date

Parent/Legal Guardian Email*

example@example.com

Parent/Legal Guardian Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Has the Client used any indoor tanning beds within 6 months?*

YesNo

Does the Client have any known food or drug allergies?*

YesNo

What type of allergies?*

Is the Client currently pregnant or breast feeding?*

YesNo

Does the Client have any respiratory ailment?*

YesNo

Does the Client have any cardiovascular ailment?*

YesNo

Does the Client have high-blood pressure or hypertension?*

YesNo

Has the Client had any surgery within 6 months?*

YesNo

Has the Client undergone any skin treatment inside a clinic before?*

YesNo

If yes, please tell us what kind of treatment, when, and the name of the Beauty Clinic:*

Is the Client 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 the Client is taking ANY of the following medications, it is recommended by Farrah Rose LLC that the Client and their parent/guardian consult with their 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 my or the Client's sensitivity to the ultraviolet raditiation. Consult a physician before using any sunlamp or tanning equipment if you/Client are using medications or have a history of skin problem or believe to yourself/Client to be especially sensitive to sunlight.

- If you/Client do not tan in the sun, you/Client 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.

WAIVER

I understand the risk of indoor tanning to the Client's 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 at Client's own risk. I understand that at any given time that the Client may be the only person inside the building. I hereby abslove Farrah Rose LLC of any liabilities, claims, or lawsuits regarding myself or the Client for any injuries or claims obtained while on the premise.

I hereby absolve Farrah Rose LLC of any liabilities, claims, and lawsuit for I and the Client were forewarned of the risk of indoor tanning to Client's 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.

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

YesNo

Client Signature*

Date Signed*

Date

Farrah Rose GLO Lounge Release Form

Consent