Sonoma County Piercing Informed Consent and Release Form
Let us do this part
Today's Date:
Sun Jun 16 2024 07:20
Please read and answer
Y
N
*
I am over 18 years of age and have represented this with a state issues I.D.
Y
N
*
Have you eaten or drank water in the last 4 hours
*
I confirm I am not currently pregnant
Y
N
*
Do you have a history of fainting or passing out
Details:
 

Y
N
*
Do you have a history of herpes infection at the proposed procedure site, diabetes, allergic reactions to latex or antibiotics, hemophilia or other bleeding disorder, or cardiac valve disease. If so please explain
Details:
 

Y
N
*
Do you have a history of medication use or is currently using medication, including being prescribed antibiotics prior to dental or surgical procedures.
Details:
 

Y
N
*
Do you have any other risk factors for blood-borne pathogen exposure
Details:
 

*
I acknowledge that I am making this decision alone, and I understand that it will permanently change my appearance. I have not been informed of any ability to restore the skin to its previous condition.
*
I acknowledge that infection is always possible and agree to the following aftercare instructions given to me by my piercer while healing. I have been given written aftercare instructions and understand I will be given spoken instructions after the completion of my piercing.
*
I release and forever discharge and hold harmless SONOMA COUNTY PIERCING COMPANY and ALL employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, the procedure or products used to perform the piercing.
*
By signing this form, I certify that all the above information is correct and release to James Biggers and SONOMA COUNTY PIERCING COMPANY any rights to photograph my piercing. I understand that these photographs may be used in articles, advertisements or social media to promote the piercer and SONOMA COUNTY PIERCING COMPANY.
*
I do not suffer from any physical, mental or medical impairments or disabilities, which might affect my wellbeing, as a direct or indirect, as a result of my decision to have a piercing done at this time
Y
N
*
Do you suffer from epilepsy, diabetes, hemophilia or heart conditions? Do you take any medications that may thin blood? If so please explain
Details:
 

Y
N
*
Do you suffer any allergies to latex, soaps, metals adhesives ect.. A piercer can not determined whether i might have an allergic reaction to the jewelry or any substance involved in the piercing process, I acknowledge this and understand that it is possible to have an allergic reaction. If so please explain
Details:
 

Y
N
*
Is there any other information you would like your piercer or the staff to know
Details:
 

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.
Legal Name:*
Pronoun:
Chosen name:
Address:
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.