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Dallas Glow Consent /Release of Liability Form

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 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 should tan with a spray tan. Overexposure to DHA does not cause skin damage but can result in possible orange distortion of the skin. Like most cosmetics, avoid exposure to the eyes, lips, and other parts of the body covered with a mucous membrane this should be accomplished using a barrier cream or similar form of skin barrier.

Additional Tanning Disclosures:

Spray tan solutions nor DHA protect you from UV rays from the sun and should not be thought of or treated as 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 if any information in my ‘Customer Profile Information’ listed above changes.

I have read the contents of this consent form carefully and state that I am not aware of any medical condition, 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, 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 service, product and or facility (if applicable).

Dated: June 13, 2021

First Customer's Name

First Name*

Last Name*

Phone*
First Customer's Date of Birth*
First Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
First Customer's Signature*
Second Customer's Name

First Name*

Last Name*
Second Customer's Date of Birth*
Second Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Third Customer's Name

First Name*

Last Name*
Third Customer's Date of Birth*
Third Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Fourth Customer's Name

First Name*

Last Name*
Fourth Customer's Date of Birth*
Fourth Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Fifth Customer's Name

First Name*

Last Name*
Fifth Customer's Date of Birth*
Fifth Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Sixth Customer's Name

First Name*

Last Name*
Sixth Customer's Date of Birth*
Sixth Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Seventh Customer's Name

First Name*

Last Name*
Seventh Customer's Date of Birth*
Seventh Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Eighth Customer's Name

First Name*

Last Name*
Eighth Customer's Date of Birth*
Eighth Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Ninth Customer's Name

First Name*

Last Name*
Ninth Customer's Date of Birth*
Ninth Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Tenth Customer's Name

First Name*

Last Name*
Tenth Customer's Date of Birth*
Tenth Customer's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Customer's Address
Address Line 1:
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:
City:
State/Province:
Zip/Postal:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
I HEREBY GIVE MY PERMISSION as parent or guardian of minor(s) (permission required if under 18), for this sunless tan application. I have read and fully understand this Client Release and Informed Consent Form and hereby agree to accept all of the provisions.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information Profile:
Have you ever used sunless tanning products containing DHA in Past?*
No
Yes
Do you have any known allergies?*
No
Yes

f YES, please list:
Are you allergic to latex?*
No
Yes
Are you presently pregnant?*
No
Yes
If YES, do you have a doctor's permission to tan?*
No
Yes
Are you under a doctor's care presently?*
No
Yes

If YES, please list the medical condition.
Have you ever been diagnosed with skin cancer?*
No
Yes
Do you typically tan very easily?*
No
Yes
Do you currently have skin irritations, infections, or problematic areas?*
No
Yes

If YES, please list:
Consent to have photos posted on @Dallasglow social media handles?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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