Tanning Facilities Statement of Acknowledgement Form - New York

This "Tanning Facilities Statement of Acknowledgement Form" is a part of the paperwork released by the New York State Department of Health specifically for New York residents.

The latest fillable version of the document was released on August 1, 2012 and can be downloaded through the link below or found through the department's forms library.

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_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
_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

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