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Permanent Jewelry

Let us do this part
Today's Date:
Sun Jun 1 2025 03:09
Please read and answer
Y
N
ALLERGY TO METALS*
IF SO, PLEASE SPECIFY
Details:
 
I AM AWARE THAT CERTAIN CHEMICALS, CONDITIONS, AND WEAR CAN AFFECT THE LONGEVITY AND LASTING QUALITY OF THE JEWLERY I AM RECIEVING TODAY.
I AM AWARE THAT DEPENDING ON ACTIVITY LEVELS AND LIFESTYLE THAT MY JEWLERY CAN DISCONNECT SOONER THAN ANTICIPATED.
I AM AWARE THAT I WILL BE IN CLOSE CONTACT WITH A WELDING MACHINE WHICH IN RARE OCCASION CAN CAUSE SMALL BURNS AND/OR VISION LOSS
I AM AWARE THAT THERE IS A RISK IN THE PROCEDURE TO OBTAIN PERMANENT JEWELRY, WHICH MAY RESULT IN ILLNESS, PERSONAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, TEMPORARY OR PERMANENT DISABILITY, DEALTH, PROPERTY DAMAGE, AND/OR FINANCIAL LOSS. I ACKNOWLEDGE THESE RISKS, AND ANY INJURIES I SUSTAIN MAY RESULT FROM OR BE COMPOUNDED BY THE ACTIONS, OMISSIONS, OR NEGLIGENCE OF GOLD LEAF TATTOO, INCLUDING NEGLIGENT EMERGENCY RESPONSE OR FIRST AID RESPONSE OF GOLD LEAF TATTOO. NOTWITHSTANDING THESE RISKS, I ACKNOWLEDGE THAT I AM VOLUNTARILY PARTICIPATING IN AND DESIRE TO OBTAIN PERMANENT JEWELRY WITH KNOWLEDGE OF THE DANGER INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF ILLNESS, PERSONAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, TEMPORARY OR PERMANENT DISABILITY, DEALTH, PROPERTY DAMAGE, AND/OR FINANCIAL LOSS ARISING FROM MY PARTICIPATION IN THE PROCEDURE TO OBTAIN PERMANENT JEWELRY, WHETHER CAUSED BY THE ORDINARY NEGLIGENCE OF GOLD LEAF TATTOO OR OTHERWISE. I HEREBY EXPRESSLY WAIVE AND RELEASE ANY AND ALL CLAIMS, NOW KNOWN OR HEREAFTER KNOWN, AGAINST GOLD LEAF TATTOO AND ITS OFFICERS, DIRECTORS, MANAGERS, EMPLOYEES, AGENTS, AFFILIATES, SUCCESSORS, AND ASSIGNS (COLLECTIVELY, “RELEASEES”), ON ACCOUNT OF PERSONAL OR PSYCHOLOGICAL INJURY, ILLNESS, PAIN, SUFFERING, TEMPORARY OR PERMANENT DISABILITY, DEATH, PROPERTY DAMAGE, OR FINANCIAL LOSS ARISING OUT OF OR ATTRIBUTABLE TO MY PARTICIPATION IN THE PROCEDURE TO OBTAIN PERMANENT JEWELRY, WHETHER ARISING OUT OF THE ORDINARY NEGLIGENCE OF GOLD LEAF TATTOO OR ANY RELEASES OR OTHERWISE. I COVENANT NOT TO MAKE OR BRING ANY SUCH CLAIM AGAINST GOLD LEAF TATTOO OR ANY OTHER RELEASEE AND FOREVER RELEASE AND DISCHARGE GOLD LEAF TATTOO AND ALL OTHER RELEASES FROM LIABILITY UNDER SUCH CLAIMS. THIS WAIVER AND RELEASE DO NOT EXTEND TO CLAIMS FOR GROSS NEGLIGENCE, WILLFUL MISCONDUCT, OR ANY OTHER LIABILITIES THAT NEW JERSEY LAW DOES NOT PERMIT TO BE RELEASED BY AGREEMENT.
I confirm that I:
(a) am in good health and proper physical condition and do not have any medical or other conditions that would impair my ability to participate in the procedure necessary to obtain permanent jewelry (hereinafter referred to as “the Activity”);
(b) am not experiencing symptoms of Disease or illness (such as cough, shortness of breath, sore throat, congestion, headache, muscle or body aches, chills, or fever), do not have a confirmed or suspected case of the Disease or illness and have not come in contact in the last fourteen [14] days with a person who has been confirmed to have or suspected of having the Disease. I will comply with all federal, state, and local laws, orders, directives, and guidelines related to the Activity and the Disease while on the premises of Gold leaf tattoo or participating in the Activity, including, without limitation, requirements related to hand sanitation, social distancing, and use of face coverings and safety equipment. I will also follow all instructions, recommendations, and cautions of Gold Leaf tattoo at all times while on the premises or during the Activity. If at any time I believe conditions to be unsafe. I acknowledge that Gold Leaf tattoo is relying on these statements to allow me to participate in the Activity. I hereby consent to receive medical treatment deemed necessary if I am injured or require medical attention during my participation in the procedure to obtain permanent jewelry. I understand and agree that I am solely responsible for all costs of such medical treatment and any related medical transportation and/or evacuation. I hereby release, forever discharge, and hold harmless Gold Leaf Tattoo from any claim based on such treatment or other medical services. This Release constitutes the sole and entire agreement of Gold Leaf Tattoo and me with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. If any term or provision of this Release is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Release or invalidate or render unenforceable such term or provision in any other jurisdiction. This Release is binding on and shall inure to the benefit of Gold Leaf Tattoo and me and their respective successors and assigns. All matters arising out of or relating to this Release shall be governed by and construed in accordance with the internal laws of the State of New Jersey without giving effect to any choice or conflict of law provision or rule (whether of the State of New Jersey or any other jurisdiction). Any claim or cause of action arising under this Release may be brought only in the federal and state courts in New Jersey. I hereby consent to the exclusive jurisdiction of such courts.
BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS RELEASE AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE GOLD LEAF TATTOO
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 16 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


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