If you would like to save time, please print this release, fill it out, and bring it on your first visit!
First name___________________ Last name________________________
City___________________, State_______ Zip___________
Date of Birth :___________
Please list any and all prescriptions/non prescription, any cosmetics, toiletries, and tanning accelerators.
DANGER - ULTRAVIOLET RADIATION
· I acknowledge that eye protection is provided by this facility and require to be worn when tanning and agree to comply with this requirement. I acknowledge that failure to use these when tanning may cause eye damage and cataracts.
· I acknowledge that abnormal or increased skin sensitivity or burning may be caused by certain foods, medications,(including, but not limited to, tranquilizers, diuretics, anitbiotics, high blood pressure medications, birth control pills, and skin creams),cosmetics or toiletries. Consult a physician or pharmacist before using tanning device if you are using a prescription or an over the counter medication, have a history of skin problems, or believe yourself especially sensitive to sunlight.
· I acknowledge that overexposure to ultravoilet radiation produced by tanning devices may cause burns.
· I acknowledge that repeated exposure to the ultraviolet radiation produced by the tanning devices in this facility may cause premature aging of the skin and skin cancer.
· I acknowledge that no person under 16 years of age is permitted to use any tanning device and I confirm that I am at least 16 years of age.
· I agree that I will comply with all instructions on the use of the UV system and that I am using these services at my own risk.
· I acknowledge that is facility has displayed a warning sign, which provides additional precautions and instructions, in each tanning room, and confirm that I have read the warning sign in its entirety and understand its contents.
· I agree to release and forever discharge Wissota Fitness, Tanning & Massage, and its employees and agents, from any and all actions, claims, liability and demands arising from any injury, damage or loss sustained by me in connection with my useof the tanning device provided by this facility.
· I acknowledge that if I do not tan in the natural sun I am unlikely to tan from the use of this product.
Yes, I have read and understand this warning.
Customer Signature: ________________________ Date:_____________