Piercing Release English
Let us do this part
Mon Oct 2 2023 05:24
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Piercing Service Consent and Release Form
Please read and answer
I understand that body piercing is an invasive procedure. The risks include but are not limited to: Allergic Reaction, bleeding, scarring, keloids, nerve damage, bacterial infection, viral infection, migration, or rejection of jewelry
Chosen Name if Different from Legal Name
By checking this box I confirm that I understand that I have scheduled an appointment for this service and that I will call to cancel or reschedule if I am unable to make my appointment time. I agree to show up on time for my appointment, and understand that if I am late the service may not be able to be performed.
I agree that if I fail to show up for my appointment and fail to get in touch to cancel or reschedule the appointment an appropriate amount of time prior to the appointment, or am late to the appointment, I may be required to pay a deposit for half the service price to schedule any future appointments.
I understand that this deposit will come off the total of my service at checkout at my appointment.
I understand that if I paid a deposit to schedule an appointment, and I fail to show up for my appointment and fail to call to cancel or reschedule my appointment prior to my appointment time, or am late to my appointment, I forfeit the deposit I paid to schedule the appointment.
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? -OPTIONAL
Piercing Name/Placement on Body -REQUIRED
Do you have any bloodborne pathogens, transmittable diseases, or recent illnesses? If so, please advise your piercer
I do not currently have diabetes, epilepsy, hemophilia, a heart condition, nor am I on blood thinning medication. I am not the recipient of a recent transplant. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the piercing.
OR if any of these conditions apply to me, I have disclosed them to my piercer and discussed the additional effects to my piercing they may have.
I am not under the influence of alcohol or drugs, and am consenting to be pierced without duress or coercion.
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 custodial 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 and I attest that all documentation I have provided is true and accurate.
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.