Fill Out This Form To Speed Up Your First Visit To Darque Zone.
3
Easy Steps!
Fill Out This Quick Form
Click Print (Below)
Bring The Paper (Signed) To Your
Closest Darque Zone Location
Full Name:
Address:
City:
Zip Code:
Birth Date:
Format: MM / DD / YY
Home Phone:
Format: 330-555-1212
Cell Phone:
Format: 330-555-1212
WARNING:
Some harmful
changes which may result from repealed
overexposure to UVA/UVB radiation include
cataracts, skin cancer, premature aging and
possible photosensitive reactions when using
perfumes, cosmetics, and certain drugs,
including some antibiotics and birth control
pills
Please answer the following
questions to the best of your ability.
The following questions are
necessary so that we may better serve you. Each question
MUST be answered HONESTLY.
1
Do you
tan easily?
2
Do you
regularly go into the sun?
3
Do you
have a tendency to burn?
4
Do you
have any known allergies to sunlight?
5
Have
you ever suffered a major sunburn?
6
Have
you ever been advised by a physician to stay out of
the sun?
7
If so,
what was the reason?
8
Are you taking any medication that would cause
sensitivity to sunlight?
(please review the list below)
Other
Drugs (Phenothlazines espec
Chlorpromazine, Thlayldes; Psoralens,
Sulfonylurea)
Others (Oral Contraceptives, Sunscreens,
Tar, Cosmetics (due to presence of
eosin, psoriases or antimicrobial
agents)
Precautions
are necessary for safe tanning. I agree that I will comply
with all instructions on the use of the tanning system
and that I am using these services at my own risk and
protecting my vision by using the goggles provided.
We and our employees and
agents are not liable for any injury to person or property
caused in any way by the use of its services or premises.
Also, they are not liable for the loss or theft of any
personal property. Each person is responsible for
safeguarding his or her own property.
