Jewelry Insertion/Removal

Let us do this part

Today's Date:

Thu May 2 2024 09:36

Part of the Body for the Insertion:*

Please read and answer

Risks for my jewelry*

I acknowledge that while every attempt will be made to handle my jewelry carefully and professionally, this handling of my jewelry during insertion or removal may result in signs of use on my jewelry apparent visibly or otherwise physically. The risk of handling my jewelry includes but is not limited to scratches, bends, dings, dents, discoloration, hardening or softening of metal, and loss of stones if any are present on or in my jewelry.

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Release*

I HEREBY WAIVE, RELEASE, AND HOLD HARMLESS, to the fullest extent permitted by law, the facility Body Manipulations and its agents from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise.

Wellness*

Do you have any of the following symptoms: fever, cough, shortness of breath, body aches?

Eaten*

Have you eaten in the past 3 hrs?

Alcohol*

Have you consumed alcohol within the last 12 hours?

Blood*

Do you have any bleeding disorder, hemophilia, diabetes, or cardiac valve disease, any other heart condition, or taking any blood thinning medication?

Photography*

I release all rights to any photographs taken of me, the piercing, and/or my jewelry and give consent in advance to their reproduction in print or electronic form.

Sound Mind*

I am fully aware and of sound mind to request this body art procedure and do not wish mutilation or harm upon myself.

This Form*

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute or under duress. I understand that I am signing a legal contract, and I agree to be legally bound by it.

Insertion/Removal Risks*

I acknowledge that insertion or removal of jewelry may result in a permanent change to my appearance and that my skin may not be restored to its pre-insertion condition even after its removal. I have been fully informed of the risks, associated with having jewelry inserted or removed. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, keloiding, and allergic reactions. Having been informed of the potential risks associated with having jewelry inserted, I still wish to proceed with the insertion/removal and I freely accept all risks that may arise from inserting or removing jewelry.

Please take photo(s) of your jewelry being inserted if it is available. For removals, get help from a friend or our staff for a photo of the piercing being removed (if appropriate).

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Legal Name:*

Pronoun:

Chosen name:

Address:

Postcode:

Date of birth:*

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID

Please take photo(s) of your government issued photo IDs and related paperwork.