T rebmuN tneilC/ / etaD syado
sutatSelddiMtsriFemaN tsaL
Single Married
yB derrefeRedoC piZetatSytiCsserddA teertSemankciN
What is your skin type?
Birth Date Age Sex Email Address Contact Phone No.
Selectone” of the following statements and check the appropriate boxes that best describe how your skin tans.
T ylidaer nat nrub yleraR ~ 4 epyTnat reven nrub syawlA ~ 1 epy
Type 2 ~ Almost always burn – sometimes tan Type 5 ~ Never burn - always tan
Type 3 ~ Sometimes burn – always tan
Do you freckle?
Yes No
Are you sensitive to sunlight? Yes No
Is there a history of skin cancer in your family? Yes No
Do you currently or have you in the past had skin cancer? Yes No
Do you currently take any medications, which may cause sensitivity to sunlight? Yes No
(anti-biotic, diuretic, birth control, over-the-counter)
The following information is very important for you to review and fully understand.
Once you have finished please complete your acknowledgement by signing the form below.
Failure to use the eye protection provided to you by GLO SUN SPA may result in permanent damage to the eyes; also overexposure to
ultraviolet light causes burns; and repeated exposure may result in premature aging of the skin and skin cancer.
Abnormal skin sensitivity or burning may be caused by reactions to ultraviolet light to certain:
Medications, including Tranquilizers
High blood pressure medicines Birth control pills
Any person taking a prescription or over-the-counter drug should consult a physician before using a tanning device. Pregnant women should consult their
physician(s) before using a tanning device. A person with skin that always burns easily and never tans should avoid a tanning device; also a person with
family or past medical history of skin cancer should avoid a tanning device.
By state law a full twenty-four (24)
hours must pass between each tanning session. The facility operator has the right to determine the amount of exposure
time within the regulations of the FDA and State, and can refuse service and limit the amount of exposure time if the operator feels like the exposure
would cause harm to the customer. Exposure time will be based on skin type and current condition of skin. Compliance with the notice requirement does
not affect the liability of a tanning facility operator or a manufacturer of a tanning device. Only Salon approved lotions are permitted for use in the tanning
equipment, and damage or excessive cleaning due to using non-approved lotions will be at cost of the customer.
I understand the instructions for proper use of the tanning devices I will use at GLO SUN SPA, I will use these tanning devices at my own risk of injury
and hereby release the owners operators, and manufactures from any liability from my improper use of these tanning devices.
For customers 18 years of age and older: My signature and date acknowledges that I have read the and understood the above liability notice and the
warning signs posted in the entry area and tanning room(s). In addition, I agree to wear protective eyewear.
Signature: Date:
For customers under the age of 18 years of age (parent or legal guardian signature required). My signature and date acknowledges that I have read and
understood the warnings given by the tanning facility operator to include the above liability notice and the warnings posted in the entry area and tanning
rooms. I consent to the minor’s use of a tanning device and agree that the minor will use protective eyewear. In addition, if the minor is under the age of
15 years, I will remain at the tanning facility while the person under 15 years of age is using a tanning device or if the minor is under the age of 13. I have
provided a letter for a physician stating the medical necessity and permission to use a tanning device.
Guardian Signature: Date:
Relation to Minor:
Mr. Miss
Mrs. Ms.
Guardian Phone:
Guardian Printed Name:
1. Fill out form
2. Print form
3. Sign & Date
4. Under 18 - Guardian
Signature Required
rev. 7/09 adp