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Client Health Questionnaire
Please complete the form below
Step 1 of 2
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Personal Details
Name
*
First
Last
Phone Number
*
Email
*
Doctors Surgery Name
*
Your Date of Birth
*
Date Format: DD slash MM slash YYYY
Emergency Contact Information
*
First
Last
Emergency Contact Phone Number
*
Your Address
*
Street Address
Address Line 2
City
Post Code
Health Questionnaire
Have you had a Spray Tan before?
Yes
No
Is your skin tone
Fair
Medium
Dark
Is your Skin
Dry
Normal
Oily
Have you had any surgeries in the last 3 months?
*
Yes
No
Please provide details.
*
Do you have Asthma or any other Respiratory problems?
*
Yes
No
Please provide details.
*
Have you had any piercings, tattoos, or permanent cosmetics in the last 3 months?
*
Yes
No
Please provide details.
*
Are you using any Retinol Products or Alpha Hydroxy Acid Products?
Yes
No
Do you take any Medication?
*
Yes
No
Please provide details
*
Have you ever experienced claustrophobia?
Yes
No
Do you have any Allergies?
Yes
No
Please provide details.
Female Clients Only Section
Are you Pregnant?
*
Yes
No
Are you Breastfeeding
*
Yes
No
Any menopause related problems?
Yes
No
Please provide details
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Consent
*
I agree to the above disclaimer
New Client Waiver Disclaimer
You have agreed to participate in a Mobile Spray Tan by Mist Me to achieve a sunless tan on your skin. To help you best achieve your desired results, please read the following material carefully.
1. A Spray Tan from Mist Me will not prevent
y
our skin from burning in the natural sun or in a tanning bed, like a base tan will. Please take the proper precautions when tanning with UV light exposure.
2. Maintaining your colour is possible with subsequent visits of every 7-10 days. Healthy, hydrated skin will hold results longer and achieve colour faster. Mist me will provide pre and post-session skincare regimen.
3. It is recommended to wait at least 8 hours (3-6 hrs for lighter shades,) before showering or bathing. NOTE: It is not recommended to participate in any activities that may cause you to perspire excessively before your first shower.
4. More than one spray tanning session in a 24 hour period is not recommended.
5. All the components of the Mist Me tanning formulation have been used in cosmetics and food products for decades and have proven to be safe for the skin. If you have ever had any ad
v
erse effects utilising self-tanning products or moisturisers, you may experience similar effects with Mist Me formulations and products. Please inform your us if you have experienced any adverse effects to sunless tanning products.
6. All active ingredients in the Mist Me formulations are FDA approved for use as a self-tanning skin agent. However, the FDA has not specifically approved the ingredients for use in a spray-on mist application. As a precaution, we recommend taking protective measures and if a user chooses, he or she can request protective eyewear, nose filters, and lip balm from Mist Me. We also recommend that you wear protective undergarments.
7. If you choose not to use the recommended inhalation protection or eye
w
ear, we recommend that you hold your breath and close your eyes during the actual misting process over the face, which lasts approximately 5 seconds.
8. Use of personal garments should be of the dark kind as the DHA in Mist Me solution may temporarily stain them. After tanning
and re-dressing, the initial bronzers may transfer to your clothing if you pursue strenuous physical activity causing perspiration. Since the bronzers are water-soluble, they will wash out.
9. Many customers wear disposable shower caps (provided by Mist Me) to keep the solution from getting in their hair. Others tan without covering their hair. The solution cannot penetrate hair follicles and there have never been any cases where the tanning solution has permanently changed anyone's hair colour.
10. If you have any history of asthma or a respiratory condition that could be aggravated by spray tanning with Mist Me, please consult a physician before using it and be sure to apprise us of any past allergic reactions to DHA products.
11. Ingredients used in Mist Me solution contain a sugar base. Spray tanning may cause your blood sugar levels to rise. Please consult with a physician before using Mist Me if you have a diabetic condition.
12. I, the undersigned, understand and will comply with all instructions for proper use of Mist Me. I am using these services at my own risk. I hereby authorise and direct employees or agents of the Business to perform such tanning procedures as may be deemed necessary or advisable, and have provided them with the above information required.
I hereby relieve and hold them harmless from any liability involved in the use of the tanning process. The Business and their agents or employees are not liable for any injury to person or property or the loss or theft of any personal property. I know that this facility does not carry liability insurance for injuries caused by tanning devices. I will not tamper with the tanning device. I have been made aware that Mist Me reserves the right to cancel package without reimbursement for customers who are verbally abusive, act of inappropriate behaviour, do not adhere to Mist Me rules, and/or act in a destructive or harmful manner. I understand that packages are sold on a per person basis and are not sharable or transferable.
ALL SALES ARE FINAL. I have read the above conditions and information on Mist Me
spray tanning.
Client Consent
I hereby consent to and authorize the esthetician to perform a Spray Tan Treatment.
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved by the esthetician whose name listed below.
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.
I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.
I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.
I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
Consent
*
I agree to the above disclaimer
Consent
Yes, please keep me updated on your latest Mist Me Offers and Promotions.
Todays Date
*
Date Format: MM slash DD slash YYYY
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