Five and Dime Services Consent Release Form
Let us do this part
Today's Date:
Tue Oct 27 2020 02:43
Practioner:*
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/or written instructions until healing is complete.

I fully understand that any/all aftercare measures, not approved by Five and Dime, that i decide to follow on my own without consulting Five and Dime, is at my own risk.

I am in full understanding of the possible complications such as, but not limited to, infection, allergic reaction, migration and/ 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 assignee's thereof (collectively) the perpetual, irrevocable, global and unrestricted right to use, reproduce, publish and copyright my picture(s), likeness, of/and voice along with video in/or 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.

TOOTH GEMS:
I understand that Five and Dime Tattoo and its agents make no claims, warranties, or guarantees as to the safety of any materials including but not limited to the jewelry itself, glues or any other products used in the application of the tooth gem.

I understand that having this service is temporary.

I understand that if my Tooth Jewelry falls out for any reason except mistreatment or failure to properly follow aftercare guidelines during the two weeks following the procedure, it will be replaced at no charge. After two weeks there is no guarantee, or warranty of replacement. If I wish to have another tooth jewelry installed, I will bear the cost of the service and jewelry myself.

If my teeth or any other body part, is harmed in any way from having this service done, I myself will be responsible for any and charges that will be made to me for the repairs by a professional. (I.e. chipping, biting, etc.)

If in the event I no longer wish to have my tooth jewelry, I myself will be responsible for all charges that will be made to me by a dental professional in the removal of my tooth jewelry.

ALL services , procedures, jewelry sales and tooth gem installations are final.

No refunds and No exchanges of any kind.

****For the current COVID-19 update: Please understand that in order to keep up with the current Covid19 Health orders: ***

*Services that require the removal of face covering/mask are prohibited. (All Nostril & Oral Piercings)

*If i proceed to still make an appointment, i understand that my appointment can and will not be confirmed, and I will also forfeit and lose my deposit. 

I have read and understand all sections of this contract to its entirety.
Please read and answer
 
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TATTOO PIERCING PERMANENT MAKEUP JEWELRY REMOVAL/INSERTION

Y
N
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Do you have a fever over 100.4 degrees or felt hot or feverish in the last 21 days?
Y
N
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Are you currently experiencing shortness of breath or other difficulties breathing? Do you have a cough?

Y
N
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Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Y
N
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Have you experienced recent loss of taste or smell?

Y
N
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Are or Have you had contact with any confirmed COVID-19 positive patients?

Y
N
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Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Y
N
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Have you traveled in the past 14 days to any regions affected by COVID-19?

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.
Name:*
Address:*
Date of birth:*
You must be 18 or older
Phone #:*
Email:*
Social Handle:
If you don't mind us tagging you in photos online
Signature:*


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