Piercing Release Release Form

Let us do this part
Today's Date:
Thu Jul 2 2020 06:00
Artist:*
Preferred Name:*
Student?:*
How did you hear about us?:*
Piercing Name/Placement:*
Allergies:*
Medications:*
Medical Conditions:*
Piercing Service Consent and Release Form

•I hereby certify that to the best of my knowledge this information is correct
•I have been given a chance to ask questions and they have been answered to my satisfaction
•This is to certify that I am at least 18 YEARS OF AGE
•I have eaten within the last 4 hours
•I am not under the influence of ALCOHOL OR DRUGS
•I understand there is a possibility of an allergic reaction
•I understand there is a possibility of infection
•I agree to the tattoo artist’s placement of the piercing
•I agree to follow all instructions given to me by Chameleon Ink, LLC and its employees concerning the care of my piercing
•I understand there is a chance I might feel lightheaded, dizzy, and/or faint before during, or after the procedure
•If you feel this way during or after the procedure, please let us know immediately.
•I hereby release Chameleon Ink, LLC and its employees of all responsibility for said BODY PIERCING(S)
•NO REFUNDS
Please read & answer
Diabetes

Epilepsy

Asthma

Infections

Hemophilia

Blood Thinners

Heart Condiiton

Faint or Dizzy

Immune Condition

Steroid Medication

Psoriasis/Eczema

TB

Scarring/Keloids

Herpes

Hepatitis

HIV/AIDS

Pregnant

Nursing

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.
Personal Info
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.
Legal name:
Pronoun:
Prefered name:
Address:*
Date of birth:*
If you are under 18 your parent/guardian
Phone #:
Email:
Signature:*


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