⇠
Still Gold Tattoo: Body Piercing
Let us do this part
Today's Date:
Tue May 19 2026 12:08
Practitioner:*
Body piercing location :*
Description of piercing :*
Lot numbers :*
Signature:*

Still Gold Tattoo
1030 W Colorado Ave.
Colorado Springs, CO. 80904
719-634-8520
Photo Identification *
Please take photo(s) of your government issued photo IDs and related paperwork
Please read and answer
Diabetes
Epilepsy
T.B.
Hepatitis
H.I.V
Hemophilia
Scarring/ Keloids
Pregnant/ Nursing
Heart Conditions
Eczema/ Psoriasis
Herpes
Blood Thinners
Skin Disease/ Lesions
Infections
Asthma
Y
N
IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath.

PLEASE NOTIFY A STAFF MEMBER IMMEDIATELY.
Y
N
Have you eaten in the past few hours? We recommend eating 2-4 hours before hand to increase your blood sugar levels.
I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.
I acknowledge that the piercing will result in a permanent change to my appearance and that m y skin may not be restored to its pre-piercing condition even after its removal.
Y
N
Do you have, or have you in the past, had any allergies/adverse reactions to latex/disinfectants/soaps/metals/dyes or pigments? If yes, please list them below:

Details: 
I affirm that I informed the piercer, of any medical conditions such as: diabetes, epilepsy, hemophilia, a heart condition or take blood thinning medication. I do not have any other medical or skin conditions that may interfere with the procedure or healing of the piercing. I am not pregnant or nursing.
I affirm that the Artist has given Me written and verbal aftercare instructions on the care of my piercing while it is 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.
That both the Artist and the Piercing Studio have given me the full opportunity to ask any and all questions about the piercing procedure and the they have been answered to my total satisfaction.
TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Piercing Studio 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 either the Artist or the Piercing Studio, or otherwise.
That I have been fully informed of the risks, associated with getting a piercing. I understand that these 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 understand that there are NO Refunds
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.
I release all rights to any photographs taken of me and the tattoo or piercing and give consent in advance to their reproduction in print or electronic form for advertising/ promotional purposes. I also release the rights to any possible reviews I may write in regards to my body art procedure that may also be used for advertising/ promotional purposes. (If you do not tick this provision, please advise your Artist). Note: No photos of minors will be taken
Y
N
I am at least 18 years of age. If giving permission to pierce a minor, please write the minor‘s name below:

Details: 
Y
N
I attest as the Parent or Legal Guardian, give permission to Still Gold Tattoo, to piece my minor.

Guardians address and DOB:

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

Parent/Legal Guardian
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.
If under 18, we need child AND parent / legal guardian(s) signatures and proper ID or Birth Certificate, the last names MUST match and be shown prior to procedure. Home address for child and parent MUST match. Parent/ legal guardian must remain present during entire procedure.
Legal Name:*
Relationship:*
Signature:*