Body Piercing Release form

Let us do this part

Today's Date:

Fri Apr 19 2024 03:43

Practitioner:*

Body Piercing placement:*

Being of sound, mind and body, I hereby release any and all persons representing Five & Dime Tattoo / Piercing from ALL responsibility.

I accept any and all responsibility for any consequences that might stem from my decision to have any services or any related work done by Five & Dime Tattoo/Piercing.

I agree to not sue anyone in connection with any and all damages, claims, judgments, rights and causes of action arising from my decision to have services from Five & Dime Tattoo/Piercing, whether or not caused by any negligence of anyone.

I agree for myself and my heirs, assigns, and legal representatives to hold Five & Dime Tattoo/Piercing harmless from all damages, actions, causes of actions, claims, judgments, cost of litigation, attorney fees and any other costs and expenses which arise from my decision to have services/ and or related work done by anyone representing Five & Dime Tattoo/Piercing.

I agree to pay for all damages and injuries to any and all persons and property belonging to Five & Dime Tattoo/Piercing, and any persons to whom may become liable contractually or by operation of law caused by, or resulting from any decision to have any services/ and or related work done by anyone representing Five & Dime Tattoo/Piercing.

I agree to leave the premises of/and or any other establishment where Five & Dime Tattoo/Piercing is engaged in business, promptly upon request, for any reason whatsoever, by any agent or employee at any time.

I agree that these waivers also pertain to and are designed to protect and all establishments where Five & Dime Tattoo/Piercing conducts business.

I agree to have ALL pertinent documents copied and given to Five & Dime Tattoo/Piercing for their records.

I agree to follow aftercare guidelines that are provided to me verbally and written instructions until healing is complete.

I am in full understanding of the possible complications such as, but not limited to, infection, allergic reaction or rejection.

I am in full understanding that the services being performed, I am making a permanent change to my body and no claims have been made regarding the ability to undo any changes made.

I am in full understanding that misrepresentation, falsifying of any information provided by me is a crime and I can be subject to prosecution.

I further state and certify that I am an adult over the age of 18, not intoxicated or under the influence of any drugs or alcohol, illegal substances, narcotics whether legal or illegal, and make these and all statements fully and completely of free will and sound mind.

I hereby grant to Five & Dime Tattoo/Piercing and any licensees, agents, and assignees thereof (collectively) the perpetual, irrevocable, global and unrestricted right to use, reproduce, publish and copyright my picture(s), likeness, and voice and video in any media for publicity, art, advertising, trade, or for any other lawful purpose. I understand that my image may be substantially edited, altered, or modified. I hereby waive any right to inspect or approve my image(s). in any media.I grant the right to market and sell copies of my image(s).. I also waive any right to royalties or other compensation related to my image(s).I release any and all legal representatives and assigns thereof from any claims in connection with the use of my image(s). I intend for this agreement to bind all of my heirs, assignees, personal representatives, and members of my family.

I hereby release Five & Dime Tattoo/Piercing from all manners of liabilities, claims, actions, and demands, in law or in equity, which I or my heirs might now or in the future, of now or after, by any reason of complying with my request to have services by Five & Dime Tattoo/Piercing.

I have read and understand all sections of this contract to its entirety.

Please read and answer

Eaten*

Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.

Bloodbourne Pathogens*

Do you have any transmittable diseases or recent illnesses? We need to be notified for our safety and other's safety.

Risks*

That I have been fully informed of the risks, associated with getting a piercing. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring and keloiding and allergic reactions. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept all risks that may arise from piercing.

Release*

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Piercing Studio 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.

Questions*

That both the Artist and the Piercing Studio have given me the full opportunity to ask any and all questions about the piercing procedure and the they have been answered to my total satisfaction.

Aftercare*

I affirm that I have given me instructions on the care of my piercing while it.s healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions.

Duress*

I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.

Medical Conditions*

I affirm that I do not have diabetes, epilepsy, hemophilia, nor do I have a heart condition or take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure or healing of the piercing. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as piercing. I am not pregnant or nursing.

Permanent change*

I acknowledge that the piercing will result in a permanent change to my appearance and that my skin may not be restored to its pre-piercing condition even after its removal.

This Document*

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, and I understand that I am signing a legal contract.

Attorney Fees*

I agree to reimburse each of the Artist and the Piercing Studio for any attorneys. fees and costs incurred in any legal action I bring against either the Artist or the Piercing Studio and in which either the Artist or the Piercing Studio is the prevailing party. I agree that the that the courts shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

Photography*

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

How did you hear about us?

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 or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

Name:*

Address:*

Postcode:

Date of birth:*

If you are under 18 your parent/guardian will be required

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID*

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