Hello Beautiful And Welcome To
K Tans, LLC
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: _____________