Spray Tan Consent Form

June 20, 2018

SPRAY TANNING CONSENT FORM

 

Name:  _____________________________________________

Address: ____________________________________________

City: ____________________ State: ________ Zip: _________

Phone #: _______________________________

E-mail address: _________________________

 

Have you received a spray tan or applied a sunless tanner before?   Yes or No

List any known allergies: _______________________________________________

Any related to Dihydroxyacetone (DHA)?   Yes or No

Do you have any skin conditions?   Yes or No

      If yes, please list: __________________________________________________

Do you have any respiratory illnesses?   Yes or No

Are you or could you be pregnant?   Yes or No

      If yes, do you have permission to tan?   Yes or No

Are you under a doctor’s care presently?   Yes or No

      If yes, please list the medical condition: _______________________________

 

Please read, understand and sign the following:

 

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.  However, its use in cosmetics – including sunless “tanning” products – is restricted to external application.  According to CFR, “externally applied” cosmetics are those ‘applied only to external parts of the body and not to the lips or any body surface covered by mucous membrane” (21 CFR 70.3v).

 

  • DHA reacts with the skin’s amino acids resulting in a “tan” similar looking to that of the sun.  The darker you can tan naturally, the darker you can tan with a spray tan.  Like most cosmetics, avoid exposure to the eyes, lips, and other parts of body covered with a mucous membrane.  This should be accomplished by follow the staff’s breathing instructions as to avoid inhaling or ingesting the sunless product and by applying a barrier cream.

 

  • Your spray tan should last 5-10 days depending on your skin type and how well you take care of your sunless tan.  It’s very important to keep your skin moisturized after your spray tan, avoiding long baths or showers and hot tubs.  Salt water exposure or a chlorinated pool can also shorten your spray tan.

 

  • Be advised there may be a small percentage of individuals whose skin does not react favorably to spray tanning.  Some medications such as birth control pills, hormone replacement medications, or antibiotics may alter your tan.  Please consult with your technician if you have any questions.

 

  • Following the spray tan session, please avoid: tight clothes, excessive perspiring, leather seats, and do not shower for at least 6-8 hours.  Letting solution stay on overnight without showering is recommended.  Some fabrics may be stained by the spray tanning solution, please use caution and care.

 

  • All ingredients in the product used in this procedure are intended for cosmetic use and generally regarded as safe.  There are, however, occasions where individuals may be allergic to one or more ingredients in the spray tan solution.  If this occurs, shower and discontinue use.  If severe reaction, contact a physician.  You may ask to see the ingredients prior to application

 

  • Be advised we do NOT advise being sprayed for photographic sessions, modeling assignments, weddings, etc. unless you have had a trial spray tan with us.

 

WARNING – This product does not contain a sunscreen and does not protect against sunburn.  Repeated exposure of unprotected skin may increase the risk of skin aging, skin cancer and other harmful effects to the skin even if you do not burn.

 

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

 

I have read and completely understand this consent form.

 

 

Signature: ___________________________________  Date:  _____________________

 

Witness (Employee) Signature: __________________________  Date: ______________

 

 

 

 

I HEREBY GIVE MY PERMISSION as parent or guardian of

 

_________________________________________ who is _______ years of age (permission required if under and hereby agree to accept all of the provisions.

 

____________________________________________________  Date: _____________

 

 

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