New York State Department Of Health Tanning Facilities Statement Of Acknowledgement printable pdf download

New York State Department Of Health Tanning Facilities Statement Of Acknowledgement

_l ease read the fol l ow i ng i nform ati on and acknow l edge that you understand al l w arni ngs and accept

New York State Department of Health

Tanni ng Faci li ti es Statement of A cknowledgement

Please read the followi ng i nformati on and acknowledge that you

understand all warni ngs and accept all provi si ons by si gni ng below

U LTRAVIO LET RA DIATIO N

U l travi ol et ( U V) radi ati on i s a hum an carci nogen and can cause ski n cancer " O verexposure to U V radi ati on f rom

tanni ng devi ces can cause burns and i nj ury to the ski n and eyes, prem ature agi ng of the ski n and al l ergi c

reacti ons" O verexposure to U V radi ati on can reduce i m m uni ty, m aki ng your body l ess abl e to f i ght i nf ecti on" I t

can al so w orsen exi sti ng m edi cal condi ti ons"

I will not exceed the manuf acturer' s maximum exposure time when using a tanning device.

U LTRAVIO LET RA DIATIO N SENSITIVITY

A com bi nati on of U V radi ati on and certai n f oods, cosm eti cs or m edi cati ons can i ncrease sensi ti vi ty to U V

radi ati on" Thi s i s cal l ed Iphotosensi ti vi ty"

I am aware that the use of U V radiation is not advised when eating certain f oods or when using certain cosmetics

or medications. I will consult a physician bef ore using a tanning device if I am using photosensitive medications,

have a history of skin problems or if I believe I am especially sensitive to sunlight. I am aware that if I do not tan

in the sun, I am unlikely to tan f rom the use of a tanning device.

TA NNING HA ZA RDS INFO RM ATIO N SHEET

I have read the N ew York State D epartment of H ealth Tanning Hazards In/orm ation Sheet.

PRO TECTIVE EYEW EA R

Fai l ure to use Food and D rug Adm i ni strati on ( FD A) certi f i ed protecti ve eyew ear can resul t i n severe burns or

i nj ury to the eye, such as photokerati ti s, cataracts, m acul ar degenerati on and m el anom a"

I agree to wear FD A certif ied protective eyewear .

STATEM ENT O F ACKNO W LEDG EM ENT

I have been given adequate instruction in the operation and use of tanning devices.

I have read and understand the hazards of tanning so that I can make an inf ormed u udgment about indoor

tanning and the use of tanning devices.

I verify that I am 18 years of age or older .

Si gnature of Patron

Date

Pri nt the Name of Patron

Type of Patron Identi fi cati on

Si gnature of O perator or Employee

Date

Revi sed 8/12

New York State Department Of Health Tanning Facilities Statement Of Acknowledgement