←
Body Piercing
Let us do this part
Today's Date:
Sun Oct 6 2024 09:29
Body Piercing Location:
*
Please read and answer
Are you the Client or Parent/Guardian
*
-- Select --
Client
Parent/Guardian
I will provide valid photo id
*
Can you provided a birth certificate or legal document confirming your relationship to the client?
*
-- Select --
Yes
No
Not Applicable
Y
N
Do you consent to the body piercing procedure (or on behalf of the minor under your guardianship)?
*
Y
N
Do you have ANY Cold / Flu symptoms?
*
IF YOU HAVE:
- a cold
- a fever
- flu-like symptoms
- shortness of breath
- change in sense of smell or taste
- cough
- sore throat
WE NEED YOU TO NOTIFY A STAFF MEMBER.
Y
N
Have you had Contact with anyone with Covid Symptoms in last 15 days?
*
-High Temperature
-Flu-like symptoms
-Shortness of breath
-Change in sense of smell or taste
Details:
Y
N
Do you suffer from any of the following Medical Conditions?
*
-Heart Condition/Angina
-Blood Pressure Problems
-Epilepsy/Seizures
-Haemophillia/Blood Clotting Disorders
-Skin Complaints
-Diabetes
-Allergic Response
-Prone to Fainting Attacks
-Regularly Take Blood Thinning Medicines
-Could you be Pregnant?
-Are you a Nursing Mother?
-Any other Medical Condition?
Details:
Y
N
Bloodbourne Pathogens
*
Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses?
Details:
Risks
*
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.
Waiver
*
TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Piercer and the 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 from my tattoo, whether caused by the negligence or fault of either the Piercer or the Tattoo Studio, or otherwise.
Healing
*
I understand that after care instructions, on the care of my piercing while it's healing, are available via the website www.valhallastudio.co.uk
I have had the chance to read 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 given to me.
If any re-piercing or removal is needed due to my own negligence, I agree that the work will be done at my own expense.
Influence
*
I will not attend my appointment under the influence of alcohol or drugs, and I am voluntarily submitting to be pierced without duress or coercion.
Health
*
I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication or have made the operator aware and have checked with my GP.
I do not have any other condition that may interfere with the application 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 preventive anti-biotics.
I am not pregnant or nursing.
I do not have a mental impairment that may affect my judgment in getting the piercing.
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.
Legal
*
I agree to reimburse each of the Piercer and the Tattoo Studio for any solicitors fees and costs incurred in any legal action I bring against either the Piercer or the Tattoo Studio and in which either the Piercer or the Tattoo Studio is the prevailing party.
I agree that the that the courts in Scotland 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.
Questions
*
I acknowledge that I have been given adequate opportunity to read and understand this document, that any and all of my questions have been answered, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the Piercer and the Tattoo Studio.
Photography
*
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. (If you do not tick this provision, please advise your Piercer).
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:
*
-Month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Day-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-Year-
1914
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
If you are under
16
your parent/guardian will be required
Phone #:
*
Email:
*
Sign up for our newsletter
Signature:
*
Sign above or type signature:
Parent/Legal Guardian
I, as custodial parent or legal guardian of the above minor under 16 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.
Guardian's Legal Name:
*
Relationship:
*
-select-
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
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.
Remove Photo