PIA Change Out Waiver Release Form

Let us do this part
Today's Date:
Thu Sep 29 2022 11:18
Practitioner:*
Body Piercing Placement:*
Please read and answer
 
How did you hear about us?*
 

Y
N
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.
COVID-19*
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact.Pure Imagination Arts (“the Facility”) has put in place preventative measures to reduce the spread of COVID-19; however, infection from COVID-19 can happen anywhere and no business can guarantee or completely prevent someone from becoming infected. Further, being in any business could increase your risk of contracting COVID-19.\r\nTo prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facility’s guidelines. The facility’s guidelines can be changed at anytime as new information and technology become available
COVID-19*
I confirm that I am not presenting any of the symptoms of COVID-19 including\r\n- dry cough\r\n- runny nose\r\n- sore throat\r\n- shortness of breath\r\n- loss of sense of taste or smell\r\n- fever - temperature over 100.4 degrees
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.
Personal Info
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:*
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Social Handle:
If you don't mind us tagging you in photos online
Signature:*


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