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First & Last Name
Appointment Date & Time
Age Certification
MINNESOTA STATE MANDATE 325H.085 states that use by minors is prohibited; a person under age 18 may not use any type of tanning equipment as defined by section 325H.01, subdivision 6, available in a tanning facility in this state.
Acknowledgment of Risk
MINNESOTA STATE MANDATE 325H.05 states that exposure to ultraviolet radiation may be dangerous. Risks may include but are not limited to: premature aging of the skin, eye injury if protective eyewear is not worn, allergic reactions, increased risk of skin cancer.
Health & Medication Disclosure
The following may increase skin sensitivity:
• Perfumes and colognes containing furocoumarins.
• Compounds from natural products such as plants and fruits (their natural oils can sensitize the
skin to sunlight.
• Food and fruits that contain photosensitizing agents: celery, carrots, lime, coriander, parsley,
fennel, dill, buttercup, mustard and figs.

A partial list of known photosensitizing medications is listed below by name:

ACETOHEXAMIDE (DYMELOR) ACRIDINE PREPARATIONS (SLIGHT) AGAVE LECHUGUILLA (AMARYLLIS) AGRIMONY 9-AMINOACRIDINE AMINOBENZOIC ACID AMITRIPTYLINE (ELAVIL, ETC.) ANESTHETICA (PROCAINE GROUP) ANGELICA ANTHRACENE ANTIMALARIALS ARSENICALS BARBITURATES BAVACHE (CORYLIFOLIA) BENEZENE BENZOPYRINE BERGAMOT (PERFUME) BITHIONAL (ACTAMER, LOROTHIDOL) BLANKOPHORES (SULFA DERIVATIVES) BULOSEMIDE (JADIT) BROMCHLORSALICYLANILID 4-BUTYL-4- CHLOROSALICYLANILIDE CARBAMAZEPINE (TEGRETOL) CARBINOXAMINE D-FORM (TWISTON R-A) CARBUTAMIDE (NADISAN) CARROTS, WILD CEDAR OIL CELERY CHLOROPHYLL CHLOROTHIAZIDE (DIURIL) CHLORPROMAZINE (THORAZINE) CHLORTETRACYCLINE (AUREOMYCIN) CITRON OIL CITRUS FRUITS CLOVER COAL TAR CONTRACEPTIVES, ORAL DEMECLOCYCLINE DECLOMYCIN DIMETHYLCHLORTETACYCLINE DESIPRAMINE (NORPRAMIN, PERTOFRANE) DIBENZOPYRAN DERIVATES DICYANINE-A DIETHYLSTILBESTROL DIGALLOYL TRIOLEATE SUNSCREEN DILL DIPHENHYDRAMINE HYDROCHLORIDE EOSIN (SLIGHT) ESTRONE FENNEL FLOURESCEIN DYES 5 FLOUROURACIL GLYCERYL P AMINOBENZOATE GOLD SALTS GRASS (MEADOW) GRISEOFULVIN (FULVICIN) HEMATOPORPHYRIN HEXACHLOROPHENE (RARE) HEXACHLOROTHIAZIDE (ESIDRIX) IMIPRAMINIE HCL (TOFRANIL) ISOTHIPENCYL (THERUHISTIN) ISOTHIPENDYL LADY’S THUMB (TEA) LANTININ LAVENDER OIL LIME OIL MECLOTHIAZIDE (ENDURON) MEPAZINE (PACATAL) 9-MERCAPTOPURINE METHOTRIMEPRAZINE (LEVOPROME) METHOXSALEN (MELOYINE, OXSORALEN) 5 METHOXYPSORALEN 8-METHOXYPSORALEN MONOGLYCERAL PARA- AMINOBENZOATE MUSTARDS NALIDIXIC ACID NAPTHALENE NORTRIPTYLINE (A VENTYL) OXYTETRACYCLINE (TERRAMICIN) PARA- DIMETHLAMINOAZOBENZENE PARAPHE NYLENEDIAMINE PARSLEY PARSNIPS PENICILLIN DERIVATIVES PERIOLINE PERPHENAZINE )TRILAFON) PENANTHRENE PHENAZINE DYES PHENOLIC COMPOUNDS PHENOTHIAZINES (DYES, METHYLENE BLUE) PHENOXAZINES PHENYLBUTAZONE (BUTAZOLIDIN) PHENYTIOIN (DILANTIN) PITCH AND PITCH FUMES PORPHYRINS PROCHLORPERAZINE PROMAZINE HYDROCHLORIDE PROFRIPTYLINE PSORALENS PYRATHIAZINE HYDROCHLORIDE PYRIDINE QUINETHAZONE (HYDROMOX) QUYININE ROSE BENGAL PERFUME RUE SALICYLANILIDESSALICYLATES SANDALWOOD OIL (PERFUME) SILVER SALTS SMARTWEED (TEA) STILBAMIDINE ISETHIONATE SULFACETAMIDE SULFADIAZINE SULFADIMETHOXINE SULFAGUANIDINE SULFANILAMIDE (SLIGHT) SULFAMERAZINE SULFAMETHANIZINE SULFAPYRIDINE SULFATHIAZOLE SULFONAMIDES SULFAISOMIDINE (ELKOSIN) SULFONYLUREAS (ANTIDIABETICS) TETRACHLORSALICYLANILIDE TRETACYCLINES THIAZIDES (DIURIL, HYDRODIURIL) THIOPHENE THIOPROPAZATE DIHYDROCHLORIDE TOLBUTAMIDE (ORINASE) TOLUENE TRIBROMOSALICYLANILIDE (TBS) TRICHLORMETHIAZIDE (METHAHYDRIN) TRIDIONE TRIETHYLENE MELAMINE (TEM) TRIFLUPROMAZINE HYDROCHLORIDE (VESPRIN) TRIMEPRAZINE TARTRATE (TEMARIL) TRIMETHADIONE (TRIDIONE) TRIPYRATHIAZINE TRYPATLAVINE TRYPAN BLUE VANILLIN OILS WATER ASH XYLENE YARROW
UV + Red Light Therapy Disclosure
MINNESOTA STATE MANDATE 325H.05 states that exposure to ultraviolet radiation may be dangerous. Risks may include but are not limited to: premature aging of the skin, eye injury if protective eyewear is not worn, allergic reactions, increased risk of skin cancer.
Protective Eyewear Agreement
MINNESOTA STATE MANDATE 325H.05 states that exposure to ultraviolet radiation may be dangerous. Risks may include but are not limited to: premature aging of the skin, eye injury if protective eyewear is not worn, allergic reactions, increased risk of skin cancer.
Skin Type & Exposure
SKIN TYPE I - Sensitive Skin - This individual burns easily and should NOT tan.
SKIN TYPE II - Light Skin - This individual burns easily and severely and should tan minimally.
SKIN TYPE III - Normal Skin - This individual burns moderately and tans moderately.
SKIN TYPE IV - Dark Skin - This individual burns minimally and tans well/ above average.

MANUFACTURER'S RECOMMENDED EXPOSURE TIME (IN MINUTES):
SKIN TYPE I - Tanning Not Advised
SKIN TYPE II - WK One: 2 Minutes, WK Two: 4 Minutes, WK Three: 8 Minutes, WK Four and beyond: 12 Minutes
SKIN TYPE III - WK One: 3 Minutes, WK Two: 5 Minutes, WK Three: 9 Minutes, WK Four and beyond: 12 Minutes
SKIN TYPE IV - WK One: 4 Minutes, WK Two: 6 Minutes, WK Three: 10 Minutes, WK Four and beyond: 12 Minutes

Tanning more than once every 48 hours is not allowed. No more than 3 tanning sessions are allowed per week.
Release & Waiver of Liability
We ask guests to acknowledge these sections so we can be sure everyone understands the safety guidelines and how to tan responsibly. It confirms that important information — like exposure timing, eyewear use, and skin sensitivity — has been clearly reviewed. This helps us provide a safe, professional experience for every guest. It’s simply part of our commitment to your safety and great results.
Accuracy Statement
This section confirms that the information you shared with us is accurate. Agreeing to keep us informed helps us protect your skin and tailor your sessions responsibly. It’s part of creating a safe and personalized experience for you.
By typing my full name above, I acknowledge that I have read, understand, and agree to this consent and waiver.