KTans

Airbrush Spray Tanning Consent/ Release of Liability Form

Customer Contact

Name___________________________________________________ Age____ M/F______

Address ________________________________________________ City___________________

State____ Zip__________

Home Phone_______________________ Cell Phone _____________________

Email___________________________________________

Emergency Contact Name and Ph# _________________________________________________/______________________

Relationship: Friend/ Spouse/ Family _______________________________

How did you hear about KTans _________________________________________________________

Referrals Name ________________________________________________________________

Customer Information Profile:

Have you ever used sunless tanning products in the past containing DHA?                                                   YES     NO

                 IF YES did you experience any negative side effects or problems?                                                      YES     NO

Do you have any known allergies?                                                                                                                                   YES      NO

                 IF YES. Please list ____________________________________________

Are you allergic to Latex?                                                                                                                                                    YES     NO

Are you Pregnant?                                                                                                                                                                  YES     NO

                 IF YES. Do you have Doctors permission to tan?                                                                                      YES     NO

Are you under a doctor’s care presently?                                                                                                                        YES    NO

                 IF YES. Please list the medical condition(s) _______________________

Have you ever been diagnosed with Skin Cancer?                                                                                                      YES    NO

I typically tan very easily?                                                                                                                                                      YES    NO

I currently have skin irritations, infections, disease or problematic areas

                 IF YES. Please list:______________________________________________

Tanning Solution Active Ingredient

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: DHA has been approved by the FDA. However its use in cosmetics- including sunless “tanning” products – is restricted to external application. According to the CFR, “externally applied” cosmetics are those “applied only to external parts of the body surface covered by mucous membrane” (21 CFR 70.3v). DHA reacts with the skins amino acids resulting in a “tan” similar looking to that of the sun. Overexposure to DHA does not cause skin damage but can result in a distorted discoloration of this tan. Like most cosmetics, avoid exposure to the eyes, lips and other parts of the body covered by mucous membrane which can be accomplished by using a barrier cream or clothing.

Additional Tanning Disclosure

Airbrush Spray Tan solutions nor DHA protects you from UV rays from the sun and should not be thought of or treated as a sunscreen or similar sun protector.

I have been verbally instructed on the pre-tanning/ preparation procedures as well as the post- tanning procedures by the airbrush technician at this business.

I understand and agree that this release of liability is perpetual and ongoing and it is my responsibility to notify this business of any information I my “Customer Profile Information” Listed above changes.

KTans has the right to refuse service to any persons without reason.

KTans does not issue refunds after the client has received his or her session

I have read the contents of this consent form carefully and state that I am not aware of any medical conditions, allergies, or any other reason that would prohibit me from sunless tanning. I have been given adequate instructions for the proper use of the sunless application, under the risks involved, and use it at my own risk. I hereby agree to release the owners, operators and manufacturers from any damages that might incur due to the use of this service, product and facility (if applicable).

(Must be 18 years or older)

Printed Name: _____________________________________________

Signature: ______________________________________________ Date: ____________________

(Parent Or Guardian)

I HEREBY GIVE MY PREMISSION as a parent ( ) or guardian ( )

Of _____________________________ Who is ____ years of age (permission required if under 18), for this sunless tan application. I have read and fully understand this Client Release and Information Consent Form and hereby agree to accept all of the provisions.

Print Name: ________________________________________________

Signature: _________________________________________________ Date: ______________________

{For illiterate or Visually Handicapped persons, this release form has been read to the use in my presence.}

Witness: ____________________________________________ Date: ____________________

              ________________________________________________________________________________________

For Technician Use only:

Skin Type:                                                                                                                                                1 2 3 4 5

Skin Condition:                                                                                                                       Dry/ Normal/ Oily/ Sensitive

Any Noticeable akin areas of concern:

Any Noticeable akin areas of concern:

_____________________________________________________________________________________

______________________________________________________________________

Tan Technician Signature: ________________________________________ Date: _____________