Signup Form | La Bella Sole

Date *

MM/DD/YY

First Name *

Last Name *

Address *

Street address and apartment number

City *

Prov *

Postal Code *

Birthday *

MM/DD/YY

Telephone *

Home

Telephone *

Work

What brought to you to La Bella Sole *

Sign

Flyer/Coupon

Radio

Internet/Website

Walk In

Beferral

Newspaper

Facebook /My space

1. Do you tan easily *

Yes

No

2. Do you regularly go into the sun ? *

Yes

No

3. Do you have a tendency to burn ? *

Yes

No

4. Do you have any known allergies to sunlight ? *

Yes

No

5. Have you ever suffered a major sunburn ? *

Yes

No

6. Have you ever been advised by a physician to stay out of the sun for medical reason ? *

Yes

No

7. Are you taking any medication that would cause sensitivity to sunlight ? Please review the list below. *

Yes

No

Tetracycline (especially Demeolocycline) Griseofulvin

Phenothiazines (especially Chlorprmazine) Psoralens

Sulfonamides (especially Sulfanilamide) Sulfonyluress

Halogenated Salicylanilides Thiazides

Others: Oral contraceptives, Sunscreens, Tar, Cosmetics (Due to the presence of Eosin, Psoralens or Antimicrobial angents)

Choose your Skin type. *

1

2

3

4

5

6

#

Characteristics

Skin response to tan

1

Unexposed skin is bright white

Blue or green eyes, Red or blond hair, freckles

Heritage is English, Irish, Scottish or Northern European

Always burn easily and severely

Peel easily

Do not get a XXXX

2

Unexposed skin is white

Blue, XXXXXX or brown eyes, Red or blonde or brown hair

Heritage is the same as in Skin type 1 or Scandinavian

Burn easily and severely

Peel easily

Tan Minimally or lightly

3

Unexposed skin is fair

Brown eyes, Dark hair

Heritage is Central or Southern European (Spanish, Greek or Italian)

Burn moderately

Tan average

4

Unexposed skin is light brown

Dark eyes, Dark hair

Heritage is Mediterranean, Oriental or XXXXX

Burn Minimally

Tan easily and above average with each exposure

Exhibit immediate darkening ofthe skin

5

Unexposed skin is brown

Dark eyes, Dark hair

Heritage is East India, Arabian. XXXX Latin or African American

Rarely Burn

Tan easily and asubstantially

Always exhibit immediate darkening of the skin

6

Unexposed skin is black

Dark eyes, Dark hair

Heritage is African American or Aborigine

Rarely Burn

Tan easily and pofusely

Always exhibit immediate darkening of the skin

PRECAUTIONS ARE NECESSARY FOR SAFE TANNING. I AGREE THAT I WILL COMPLY WITH ALL INSTRUCTIONS ON THE USE OF THE UV TANNING SYSTEM AND THAT I AM USING THESE SERVICES AT MY OWN RISK. I AGREE TO PROTECT MY VISION BY ALWAYS WEARING PROPER SUN TANNING GOGGLES. LA BELLA SOLE TANNING LOUNGE, IT'S EMPLOYEES AND AGENTS ARE NOT LIABLE FOR ANY INJURY TO PERSONS OR PROPERTYTHEFT OF ANY PROPERTY. EACH PERSON IS RESPONSIBLE FOR SAFEGUARDING HIS OWN PERSONAL POSSESSIONS.