New Tanning Client Intake

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Email

example@example.com

Phone Number

Area Code Phone Number

Date

How did you hear about us? If from a friend, add their name to the "other" section:

Google Yelp Facebook Twitter Instagram Other website Friend

Skin type:

Dry Oily Combination Acne prone Sensitive Normal

Are you pregnant?

No Yes/maybe

Have you ever tried any of the following sunless products in the past?

Spray tan automatic booth Airbrush technician Sunless lotion Sunless spray None of the above

Have you ever had a reaction to any of the above products? If yes, please describe in "other" section:

No Yes

Do you have any allergies? If so, please list in "other" section:

No Yes

Are you over the age of 18? Please type your birthday in "other" section:

Yes No

Are you allergic to DHA?

No Yes

If yes, do you have a doctor's permission to tan?

Yes No

If you're under the care of a doctor, please indicate any reason why it may be unsafe for you to tan in "other" section:

N/A, not under care of doctor

Spray tanning is accomplished by application of a solution containing the active ingredient DHA (dihydroxyacetone). DHA is considered to be safe and has been FDA approved for cosmetic use. DHA is listed in the food, drug and cosmetic 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.
DHA reacts with the skin’s amino acids, resulting in a tan similar looking to that of the sun. The darker your skin, the darker spray tan color you can have and still look natural. Overexposure to DHA does not cause skin damage but can result in possible orange coloring of the skin. Please follow the advice of the spray tan technician.
What you wear is up to you and your level of comfort. Men are required to wear bottoms. It is recommended that you wear an old dark swimsuit or underwear. While the solution should wash out of dark clothing, it is best to wash the swimsuit or clothing as soon as possible.
You will have an immediate tan after your airbrush tanning session due to the cosmetic bronzer. The sunless tan will develop gradually over the next 8-12 hours. The cosmetic bronzer will wash off after your first shower and you will be left with a more subtle tan. This is normal.
After your session, avoid tight fitting clothing/shoes, leather, perspiring, and water.
If you have any concerns at all about an allergic reaction, please ask for a list of ingredients prior to your tanning session.
We always recommend a trial run for a tan intended for important occasions such as weddings, photography sessions, modeling, etc.
Warning – This product does not contain a sunscreen and does not protect against sunburn. Repeated exposure to the sun/uv rays without the use of sunscreen may increase the risk of skin aging, skin cancer, and other harmful effects to the skin even if you do not burn.

This process has been explained to me and I hereby agree to allow a technician at Celebrity Skin Chicago to apply the sunless tanning solution to my skin. To my knowledge, I have no medical condition or allergy which would preclude me from having this procedure done. I agree to hold Celebrity Skin Chicago harmless of any and all medical complications that may arise. I have been advised to discontinue use if any reaction occurs. I have read and fully understand this client release and informed consent form and hereby agree to accept all of the provisions.

Client signature (or signature of guardian if client is under 18)

Clear