Stay Golden - New Client Intake Form-Stay Golden

First Name

Last Name

Email

Phone Number

Please select your gender:

Female

Male

Non-Binary

Do you have any allergies or respiratory issues?

Are you pregnant or breastfeeding? If pregnant, please indicate trimester.

Have you had surgery or medical treatment in the past 3 months?

Yes

No

Do you have any skin or pigmentation disorders or hypersensitivity?

Yes

No

Do you have any open cuts or rashes?

Yes

No

In the past 2 weeks, have you had any piercings, tattoos, botox or fillers?

Yes

No

Do you wear contact lenses?

Yes

No

Do you have color treated hair?

Yes

No

Have you showered/shaved/waxed within 5 hours of your appointment?

Yes

No

Have you applied deoderant or moisturizer today?

Yes

No

Have you brought loose, dark clothing to wear after your session (and umbrella if raining)?

Yes

No

Is the tan for a special occasion?

Yes

No

Have you had a spray tan before?

Yes

No

Have you completely read the pre-session prep and aftercare tips, and FDA recommendations on the Stay Golden website?

Yes

No

Are you aware that pre-session prep and aftercare is your full responsibility?

Yes

No

Please confirm you are happy to proceed with your treatment:

Yes

Are you willing to do a before & after or tan line picture? (can be anonymous)

Yes

No

Do you tan or burn in the sun?

What shade level would you like for your spray tan: light, medium or dark?

How did you hear about Stay Golden?

Do you have any questions?

I declare that I have read and understood and answered the questions to the best of my knowledge. I have read the contents of this consent form carefully and state that I am not aware of any medical condition, allergies, breathing or respiratory issue, or any other reason that would prohibit me from airbrush tanning. I have been given adequate instructions for the proper use of the sunless application with the tanning tips that Golden Tans, LLC dba Stay Golden Airbrush Tanning has instructed me to read on the website, text or emailed to me. I am aware that the results of airbrush tanning vary and that no guarantee is offered or implied. If there is any discomfort during the session, the session will immediately stop. If necessary, Golden Tans LLC dba Stay Golden Airbrush Tanning will seek medical assistance on your behalf. I agree to release Golden Tans, LLC dba Stay Golden Airbrush Tanning the owner and the property owners, operators, manufacturers from any damages that I might incur due to the use of this facility or service. I have been advised to discontinue use if any reaction occurs, understand the risks involved, and tan at my own risk. Refunds are at the discretion of Golden Tans, LLC dba Stay Golden Airbrush Tanning. It is the sole responsibility of the client to notify Golden Tans, LLC dba Stay Golden Airbrush Tanning about any changes in allergies or medication. Golden Tans, LLC dba Stay Golden Airbrush Tanning will provide a list of solution ingredients upon request, plant derivative DHA being the main ingredient. I do feel that the owner and any employees of Golden Tans, LLC dba Stay Golden Airbrush Tanning have answered my questions and have provided me with all the appropriate information for my sunless airbrush tan.

FDA precautionary guidelines for spray tanning with DHA: The FDA has advised that all users of DHA spray tanning services avoid inhaling or ingesting DHA. When using all-over sunless tanning sprays containing DHA it may be difficult to avoid exposure to sensitive areas including eyes, lips, mucus membranes or internally. The FDA recommends you take the following protective measures during your sunless tanning session:

Use of protective undergarments
Use of protective eyewear
Use of nose filters
Use of lip balm

Golden Tans, LLC dba Stay Golden Airbrush Tanning offers the following sanitary, disposable items: nose filters, face masks, undergarments, hair nets, and ‘sticky’ feet. Please request these offered items from your spray technician if you do not have them available to you. The first set is supplied free upon your request. If you have additional concerns, please consult with your health care provider. To understand the complete FDA stance on DHA please visit www.FDA.gov.

Use of Retinol and anti-aging products, acne treatment products, and products that include AHA’s and BHA’s may fade your sunless tan quicker or cause your tan to appear patchy, as they are designed to exfoliate the skin and renew to reveal the skin underneath.

I have read and understand this waiver in its entirety as well as the tanning tips and instructions. The information above is for the technicians records only and will not be misused or passed on to any other third-parties.

Your Signature

*

Date