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Tanning Information and Consent Form

The customer must sign the following form before the initial tanning session and at least annually thereafter. Signing is acknowledgement made that the customer understands all information including the warning statement.

Birthday
What is your skin type? Check the box that best describes you.

*Manufacturer's recommended exposure schedule is printed on all tanning beds.

For this next section, please add up your score for all the questions and enter the TOTAL below.

Eye Color
0 - Light blue, gray or green
1 - Blue, gray, hazel or green
2 - Brown
3 - Dark Brown
4 - Brownish/Black
Natural Hair Color
0 - Sandy, red
1 - Blond or strawberry blond
2 - Chestnut, dark blond, light brown
3 - Dark Brown
4 - Black
Color of untanned skin
0 - Reddish
1 - Very pale
2 - Pale with beige tint
3 - Light brown
4 - Dark brown
Freckles
0 - Many
1 - Several
2 - Few
3 - Very Few
4 - None
What happens when you stay long in the sun?
0 - Painful redness, peeling, blistering
1 - Burns regularly with peeling
2 - Burns sometimes with peeling
3 - Burns rarely
4 - Never burns
To what degree do you tan?
0 - Hardly; not at all brown
1 - Tans a little, a light color
2 - Tans reasonable
3 - Tans very easily
4 - Quickly turns dark brown
How does your face react to the sun?
0 - Very sensitive
1 - Sensitive
2 - Normal
3 - Very Resistant
4 - Never a problem

Based on the TOTAL number entered above, select your Type

Skin Type Point Ranges
0 - 3: Type 0
4 - 10: Type I
11 - 17: Type II
18 - 24: Type III
25 - 28: Type IV
Do you tan your whole body?
Yes
No
Have you tanned in the past 48 hours?
Yes
No
Do you have any known allergies or reactions to sunlight? e.g. hives, extreme burn, rash, fainting, cold sores.
Yes
No
Are you taking any medications, pills, or using any products that may cause photoreactions?
Yes
No

Photosensitivity can be caused by many classes of medications, cosmetics, and other products. Below are a few. Ask for a more complete list if you have concerns.

Single choice
Antihistamines
Anti-inflammatory drugs
Antibiotics & Anti-infectives
Anti-diabetic drugs
Thiazide Diuretics
Tricyclic Antidepressants
Birth Control Pills
Antiseptics
Artificial sweeteners
Psoriasis/eczema products
Medicated shampoos
Dyes
Cosmetics & Perfumes
Deodorant soaps
Bacteriostatic soaps
Flavorings and spices
Tattoos
Sunscreens
Are you pregnant? -- Consult with Physician if you are. Tanning may be inadvisable during pregnancy (for reasons such as excessive heat and folic acid depletion).
Yes
No
Have you ever had skin cancer?
Yes
No
Are you aware of negative effects related to Ultraviolet (UV) exposure?
Yes
No
Are you aware of the potential negative health effects of UV exposure that include increased risk of skin cancer later in life, premature aging and activation of some viral conditions?
Yes
No
Are you aware of exposure limits?
Yes
No

Please read the following warning statement, then sign indicating that you have read and understood the information provided. If you have any questions before signing, you may contact Beach Booty Tanning Salon at 435-669-9899 or email beachbootytanningsalonsg@gmail.com.

DANGER - ULTRAVIOLET RADIATION. Follow instructions. Avoid overexposure. As with natural sunlight, overexposure can cause eye and skin injury and allergic reactions. Repeated exposure may cause premature aging of the skin and skin cancer. 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 radiation. Consult physician before using sunlamp if you are using medications, have a viral condition, have a history of skin problems, or believe yourself especially sensitive to sunlight. If you do not tan in the sun, you are unlikely to tan from the use of this product.


AFTER READING ALL OF THE ABOVE WRITE ON THE LINE BELOW "I have read all of the above"

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