Body Piercing Release Form

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Today's Date:
Sun Sep 26 2021 12:43
Practitioner:*
What are you getting Pierced?:*
Please read and answer
 
I am not sick*
I confirm that, I am not sick and I have not been sick in the last 14 days. Also that I have not been around anyone that has been sick in the last 14 days. This includes but is not limited to Covid-19.

Medical Conditions*
-I am not pregnant or nursing.

-If I have diabetes, epilepsy, hemophilia, or a heart condition or take blood thinning medication. I have spoken with the Piercer performing my piercing before hand.

-I do not have any other medical or skin condition that may interfere with the procedure or healing of the piercing.

-I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as piercing.
Y
N
Bloodbourne Pathogens*
Do you have any bloodborne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety).
Y
N
Eaten*
Have you eaten in the past 3hrs? It's a good idea to before hand to increase your blood sugar levels.
Permanent Change*
I acknowledge that the piercing will result in a permanent change to my appearance and that my skin may not be restored to its pre-piercing condition even after its removal.
Risks*
I understand that the risks, known and unknown, can lead to injury, including but not limited to infection, scarring and keloiding and allergic reactions.

Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept all risks that may arise from piercing.

I have been fully informed of the risks, associated with changing my jewelry or stretching my healed piercing.
Release*
I waive and release to the fullest extent permitted by law each of the Artist(s), Piercer(s), and Studio(s) from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of the Artist(s), Piercer(s), or Studio(s), or otherwise.
I am not under Duress*
I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.
No Refunds or Exchanges*
I understand that once the procedure has been preformed and paid for, there are no refunds or exchanges available.
All sales are final.
Attorney Fees*
I agree to reimburse each of the Artist(s), Piercer(s), and Studio(s) for any attorneys, fees, and costs incurred in any legal action I bring against either the Artist(s), Piercer(s), or Studio(s) and in which either the Artist(s), Piercer(s), or Studio(s) is the prevailing party. I agree that the Courts of Cecil County in Maryland shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.
Photography*
I agree that if I allow the piercer to take my photograph that I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form.
I have read this document in full*
I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.
Personal Information*
I understand that my information will not be solicited, and is used for Timeless LLC's records per Maryland State Health Regulations and our insurance policy.
Aftercare*
I affirm that I have been given instructions on the care of my piercing while it's healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions.
Questions*
I have been give the full opportunity to ask any and all questions about the piercing procedure and they have been answered to my total satisfaction.
Please email us at Questions@TimelessPiercing.com with any questions before filling this out completely.
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.
Legal Name:*
Pronoun:
Preferred name:
Address:*
Postcode:*
Date of birth:*
You must be 18 or older
Phone #:*
Email:*
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Signature:*


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