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Mon Jul 26 2021 12:57
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Body Piercing Location:
Our goal is to be inclusive, fun, informative, clean and to provide a service to the best of our ability. Thank you for choosing us!
Please read and answer
We’re not doctors
I fully understand that any employee, agent or contractor of Cereal City Tattoo & Piercing Llc when performing a piercing does not act in the capacity of a medical professional. the suggestions made by any employee, agent or contractor of Cereal City Tattoo & Piercing Llc are just suggestions. They are not to be construed or substituted for advice from a medical professional.
I hereby release Cereal City Tattoo & Piercing Llc & its employees, agents and contractors, from all manner of liabilities, claims, actions & demands, in law or in Quito, which I or my heirs have or might have now or hereafter reason of complying with my request to be pierced.
I hereby assume full responsibility for my aftercare & cleanliness. I UNDERSTAND that by having this tattoo performed that I am making a permanent change to my body & no claims have or will be made regarding the ability to undo the permanent changes I am requesting be made
To ensure proper healing of my piercing & to prevent contracting any type of infection of illness (including but not limited to MRSA & COVID-19), I AGREE to stringently follow the aftercare suggestions outlined in the written tattoo aftercare instructions provided to me until the healing process is complete. I UNDERSTAND that a piercing can take up to a year or longer to fully heal.
I UNDERSTAND that by having this tattoo performed that i am making a permanent change to my body & no claims have or will be made regarding the ability to undo the permanent changes I am requesting be made
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.
M.D.H.H.S. Disclosure Statement /Notice for Filing Complaints
I have been given M.D.H.H.S. Disclosure Statement /Notice for Filing Complaints
Public Act 375, which was enacted in December of 2010, indicates that individuals shall not tattoo, brand, or perform body piercing on another individual unless the tattooing, branding, or body piercing occurs at a body art facility licensed by the Michigan Department of Community Health. Body art facilities are required to be in compliance with the “Requirements for Body Art Facilities,” which provide guidelines for safe and sanitary body art administration.
As with any invasive procedure, body art may involve possible health risks. These risks may include, but are not limited to: transmissions of bloodborne diseases such as HIV and viral hepatitis, skin disorders, skin infections, and allergic reactions.
In addition, persons with certain conditions including, but not limited to, diabetes, hemophilia or epilepsy, are at a higher risk for complications and should consult a physician before undergoing a body art procedure.
If you wish to file a complaint against a body art facility related to compliance with PA 375 or have concerns about potential health risks, please visit www.michigan.gov/bodyart.
Do you have any history of epilepsy, seizures, fainting or narcolepsy?
Do you have a history of hemophilia or excessive bleeding?
Have you had any alcoholic beverages or drugs in the last 8 hours?
Do you take antibiotics before seeing the dentist?
Have you taken any medications that thin the blood and or interfere with blood clotting (including aspirin, Tylenol, and ibuprofen” within the last 24 hours?
Do you have any history of allergies or adverse reactions to latex, pigments, dyes, disinfectants, metals, or other sensitivities related to tattoo procedures?
Do you have any additional allergies
Pregnant or Breastfeeding
Are you pregnant, have any reason to believe you might be pregnant or breastfeeding?
I AFFIRM TO THE BEST OF MY KNOWLEDGE that I & members of my immediate family (&/or household), are not currently sick & in the last 30 days: have not been sick, have not been in contact with any that is sick, & have no travelled outside of the country.
I UNDERSTAND Cereal City Tattoo & Piercing Llc has put in additional protective measures in place in order to further minimize the risk of exposure to any contamination, virus, or pathogen. I also understand it is impossible to completely eliminate that risk. I UNDERSTAND I WILL BE TATTOOED using appropriate sterile instruments & aseptic technique. I UNDERSTAND that getting a piercing does temporarily stress the body and the immune system, which could make me more susceptible to illness & infection. I ACCEPT THIS RISK. I WILLINGLY SUBMIT TO THESE PROCEDURES, with a full understanding of the possible complications such as, but not limited to: infection, illness, allergic reaction, or rejection of the piercing.
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 including use on social media and advertising.
How did you hear about us?
Your satisfaction is important to us as well as your safety and security. Thank you for taking the time to compete the form
We will help you complete it prior to your appointment.
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.
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.
Date of birth:
If you are under
your parent/guardian will be required
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Sign above or type signature:
I, as 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
Based on the listed Michigan Public Health Code, a parent
Guardian's Legal Name:
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Please take photo(s) of your government issued photo IDs and related paperwork.