Date

MM

DD

YYYY

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you use any AHA, Glycolic, or Retin-A products? *

Yes

No

Do you suffer from any medical conditions such as diabetes / high blood pressure? *

Yes

No

Have you ever had any adverse reactions to any skin care products? *

Yes

No

Do you have any known allergies? *

Yes

No

Are you currently taking any medications?

Yes

No

I understand and agree to the 48 hour cancelation policy *

I understand that if I need to cancel or reschedule my appointment, I will give at least 48 hours notice. If I am unable to give 48 hours notice, I understand that I will be charged for the price of my service appointment via invoice and I agree to remit payment for my missed appointment.

Yes

No

Date

MM

DD

YYYY

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Would you like us to recommend skincare / makeup products that we believe will benefit your skin goals?

Yes

No

Do you wax/ sugar your facial skin on a regular basis? *

Yes

No

Have you had facials, chemical peels, microdermabrasion, or any resurfacing treatments within the last 2-4 weeks? *

Yes

No

Are you using Retin-A, Benzoyl Peroxide, or any other prescription skin products within the last 3 months? *

Yes

No

Have you received any neurotoxin (botox) injections within the last 2 weeks or any other injectable procedures within the last 4 weeks?

Yes

No

Do you have any metal implants or a pacemaker?

Yes

No

Do you have any allergies or sensitivities? *

Yes

No

Do you have any of the following health issues? Cancer, circulatory issues, arthritis, hormonal imbalances, diabetes, lactating, psoriasis, cold sores, eczema, recent surgeries, pregnancy, high blood pressure, chemotherapy, thyroid imbalances, hysterectomy? *

Yes

No

Do you take any medications? *

Yes

No

I understand and agree to the 48 hour cancelation policy *

I understand that if I need to cancel or reschedule my appointment for any reason, I will give at least 48 hours notice. If I am unable to give 48 hours notice, I understand that I will be charged the price of my service appointment via invoice and I agree to remit payment for my missed appointment.

Yes

No

Date

MM

DD

YYYY

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you taking any medications?

Yes

No

Are you currently pregnant? *

Yes

No

Do you suffer from chronic pain? *

Yes

No

Have you had any orthopedic injuries? *

Yes

No

Have you had a professional massage before? *

Yes

No

Do you have any allergies or sensitivities? *

Yes

No

I understand and agree to the 48 hour cancelation policy *

I understand that if I need to cancel or reschedule my appointment for any reason, I will give at least 48 hours notice. If I am unable to give 48 hours notice for any reason, I understand that I will be charged the price of my service appointment via invoice and I agree to remit payment for my missed appointment.

Yes

No

Date

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Fitzpatrick

Skin Type

TYPE I

TYPE II

TYPE III

TYPE IV

TYPE V

TYPE VI

Skin Tone

WARM

NEUTRAL

COOL

Do you have any known allergies? *

Yes

No

Do you wear contact lenses?

Yes *if yes, please remove prior to spray

No

Please read and check each box *

I agree to have a sunless spray tan

I understand that the bronzing and tanning solutions used during this session have the potential to stain clothing

I understand that some of the ingredients contain a sugar base and application can cause a small rise in blood sugar. *If you have diabetes or a medical condition that can be affected or aggravated by a rise in blood sugar, please consult your physician prior.

I understand that the active ingredient DHA (dihydroxyacetone) is present in all sunless tanning products and does not provide any UV sun protection

I understand that there are no guarantees for the outcome of spray tan results, as everyone's skin tans differently

I understand that there are no guarantees for how long my spray tan lasts

I release my technician and C&SM from all liability associated with this service

I understand that there are many factors that may affect the life of my tan. *such as solution used, length of time until first shower, exfoliation of skin, dryness of skin, exercise, etc.

I agree that the information I have provided is correct to the best of my knowledge

I understand and agree to the 48 hour cancelation policy *

I understand that if I need to cancel or reschedule my appointment, I will give at least 48 hours notice. If I am unable to provide 48 hours notice for any reason, I understand that I will be changed for the price of my service appointment via invoice. I agree to remit payment for my missed appointment.

Yes

No