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PIA Change Out Waiver

Let us do this part

Today's Date:

Tue Apr 23 2024 06:50

Practitioner:*

Body Piercing Placement:*

Please read and answer

How did you hear about us?*

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 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:

Photo ID*

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