←

PIA Body Piercing Waiver

Let us do this part

Today's Date:

Wed Apr 24 2024 08:51

Practitioner:*

Placement of Piercing:*

Please read and answer

Eaten*

Have you eaten in the past 4 hours? It's a good idea to eat before hand to increase your blood sugar levels.

How did you hear about us?*

Bloodbourne Pathogens*

Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for our and other's safety).

Risks*

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.

Release*

I do WAIVE AND RELEASE to the fullest extent permitted by law each of the Artists 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.

Questions*

I acknowledge 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 that they have been answered to my total satisfaction.

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.

Duress*

I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.

Medical Conditions*

I affirm that I do not have diabetes, epilepsy, hemophilia/bleeding disorders, nor do I have a heart condition or take blood thinning medication. 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. I am not pregnant or nursing.

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.

This Document*

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.

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.

List any allergies, including to medications, and allergies to any topical solutions used by Pure Imagination Arts*

Race*

Some pro tips when filling out the form:

Anywhere that asks for an address should be the complete address; example: 123 Street Name, City, State, Zip Code
Please DO NOT use auto-fill. The information is not imported correctly and will likely result in having to redo this form.

The Personal Information box is for the PERSON BEING PIERCED'S (even if they are a minor) information: name, birthdate, address, etc.
For minors, once you put in their birthdate, another box for the parent/guardian's information and signature will open below the Personal Information section.

If you do not have a physician, or prefer not to list your physician, please do not type anything in the Physician Information section; it will automatically use the default of the local hospital, Beaches Baptist.

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

Gender:

Phone #:*

Email:*

Social Handle:

If you don't mind us tagging you in photos online

Signature:*

Sign above or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:*

Address:*

Physician Information

Enter your physician or medical practitioner's contact details or use our suggested default medical facility.

Name:

Contact:

Address:

Photo ID*

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