Piercing Release Release Form
Let us do this part
Tue Apr 13 2021 12:28
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Piercing Service Consent and Release Form
Please read and answer
Minor Piercing Agreement
If this piercing is for a minor, you need to submit GOVERNMENT ISSUED ID for both PARENT/GUARDIAN and MINOR. For the minor, birth certificates, state IDs, passports, tribal, or military IDs will suffice. If using a birth certificate as identification for the minor, please also provide photo ID. If using a birth certificate, a school ID will suffice as photo ID.
If you do not submit proper identification we may have to reschedule your appointment.
If this piercing is for a minor, please complete the form with the MINOR's information, NOT PARENT/GUARDIANS. Once you have completed the form and entered the minor's birthdate, a parental consent section with pop up for the parent to fill out and sign.
Please list the IDs you will be providing for the minor in the space below.
THEN submit pictures of them at the bottom of the form.
How did you hear about us?
Piercing Name/Placement on Body
Faint or Dizzy
THE FOLLOWING QUESTIONS ARE REQUIRED TO ANSWER.
I consent to receive a tattoo or piercing service(s) during the COVID-19 outbreak.
I understand there is much to learn about the newly emerged COVID-19 including how it spreads and is transmitted
I understand that based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19.
I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.
I understand that due to the unknowns of this virus, and the nature of the procedures performed within any tattoo or piercing facility, that I have an increased risk of contracting the virus if I have a body art procedure performed on me during the COVID-19 outbreak.
I understand that the symptoms listed below are representative of COVID-19:
FEVER, DRY COUGH, SHORTNESS OF BREATH, HIGH BODY TEMPERATURE, BLUISH LIPS AND FACE
I confirm that I do not display or currently have ANY of the symptoms that are representative of COVID-19, which are outlined above.
I confirm, to the best of my knowledge, that I have not had any close contact with an individual diagnosed with COVID-19 in the past 14 days.
Do you have a fever or have you felt hot or feverish in the last 14-21 days?
Are you currently experiencing shortness of breath or difficulties breathing?
Do you currently have a cough?
Are you currently experiencing any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
Have you recently experienced loss of taste or smell?
Are you in contact or have you recently had contact with any confirmed COVID-19 positive patients?
(clients who are well but who have sick family members at home are asked to reschedule at a later time, when all members of your household are confirmed healthy)
Are you over 60?
(clients who are over 60 are encouraged to refrain from getting tattooed or pierced during the pandemic)
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorder?
(clients with compromised immune systems are encouraged to refrain from getting tattooed or pierced during the pandemic. We may require a doctor's note informing us whether it is safe to tattoo or pierce you)
Have you traveled out of the region/state/country in the past 14 days?
I HAVE ANSWERED ALL QUESTIONS HONESTLY AND TO THE BEST OF MY ABILITY. I UNDERSTAND THAT IF I HAVE MISREPRESENTED MY HEALTH STATUS OR THAT OF MY IMMEDIATE HOUSEHOLD IN ORDER TO GET TATTOOED OR PIERCED, I MAY BE HELD LIABLE IN A COURT OF LAW
Positive responses to any of these questions will likely indicate a deeper discussion with your artist before proceeding with your body modification
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.
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.
Date of birth:
If you are under
your parent/guardian will be required
Sign above or type signature:
I, as parent or legal guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this release form
Body Piercing is an invasive procedure At Chameleon Ink body piercings are carried out by Body Piercing Technicians licensed in the state of WA, using sterile equipment and single-use piercing needles. We strive to minimize the risk of complications following a procedure, but problems with a piercing may occur with anyone and cannot be predicted. The risks include, but are not limited to: Allergic reaction, bleeding, scarring, keloids, nerve damage, bacterial infection, viruses or viral infection, migration or rejection of jewelry. We require the purchase of aftercare products to use while following aftercare instructions for piercings on minors I hereby acknowledge that I will take full responsibility and ensure that the proper aftercare is followed. I hereby understand that there are certain risks associated with having a body piercing performed, and should a problem develop with the piercing, medical attention may be necessary. I hereby acknowledge that I have read this document and indemnify Chameleon Ink LLC against any damages arising from this procedure. GOVERNMENT ISSUED ID IS REQUIRED FOR BOTH PARENT AND MINOR. PLEASE SUBMIT PHOTOS OF IDENTIFICATION BELOW FOR BOTH PARENT AND MINOR.
Guardian's Legal Name:
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
Please take photo(s) of your government issued photo IDs and related paperwork.