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Body Piercing
Let us do this part
Today's Date:
Sun May 5 2024 12:19
Body Piercing Waiver
Please read and answer
Y
N
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hereby give consent to Zen Ink, LLC to perform a
body piercing, and in consideration of doing so, I hereby release and forever discharge and hold harmless
Zen Ink, LLC, the Piercer/Artists and all affiliates, Owners, Managers and Independent Contractors from any and all claims, damages or legal actions arising from or connected in any way with my piercing procedure and
conduct used in my performing my piercing, to the fullest extent allowed by the law.
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N
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I fully understand that any Independent Contractors of Zen Ink, LLC when performing a body piercing, do not
act in the capacity as a medical professional. The suggestions made by any Independent Contractors or agent of Zen Ink, LLC are just suggestions. They are not to be construed as, or substituted for advice from a medical
professional. I understand that the body piercing will be performed using appropriate techniques and
instruments. I also understand that infections can occur due to lack of proper hygiene and metal sensitivities.
To ensure proper healing of my body piercing, I agree to follow the written and verbal aftercare instructions that
will be provided, until healing is complete. I understand that a body piercing may take several months to heal
properly.
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N
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I understand that I am making a modification to my body, and no claims about the possibility of reversing these changes have been made or implied by Zen Ink, LLC or any of its Independent Contractors or agents.
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N
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I understand there are no refunds.
Y
N
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I agree that these waivers also pertain to and are designed to protect any and all establishments of Zen Ink and their Independent Contractors.
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N
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I agree to speak softly and silence my cell phone in order to help keep a calm, spa like environment.
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I am at least 18 years old.
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Do you have a heart condition?
Details:
 
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N
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Do you have epilepsy?
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N
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Do you have Diabetes?
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N
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Do you have Hepatitis/HIV or any other communicable disease?
Details:
 
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N
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Do you have sunburn, discoloration, lumps around the piercing area?
Details:
 
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N
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Are you pregnant/breastfeeding?
Details:
 
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N
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Have you eaten in the last 5 hours?
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N
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Do you suffer from any condition that makes this procedure dangerous?
Details:
 
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N
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Have you consumed drugs/alcohol in the last 8 hours? if so, what and how many?
Details:
 
Y
N
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Have you recently taken: blood thinners, antibiotics, prednisone, accutane?
Details:
 
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Are you prone to fainting?
 
Are you allergic to?
Petroleum Lavender Tea tree Stainless Steel Iodine
 
How Did You Hear About Us?
Google Facebook Instagram Referral Yelp Repeat Client Other
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N
COVID-19 #1*
I am not currently sick and in the last 14 days, I have not been sick, have not been in contact with anyone that is sick.
Y
N
COVID-19 #2*
I understand that getting a piercing does temporarily stress the body and the immune system, which could make me more susceptible to illness and infection. I accept this risk.
Y
N
COVID-19 #3*
I understand the Zen Ink has put additional protective measures in place in order to reduce the risk of contamination, virus, or pathogen but it is impossible to completely eliminate that risk.
Y
N
COVID-19 #4*
I agree to release and forever hold harmless Zen Ink and its agents and representatives for any and all claims, damages, or legal actions in the event I contract COVID-19 or any other illness after choosing to get tattooed/pierced.
Y
N
COVID-Symptoms*
Have you experienced any symptoms (fever, cough, shortness of breath, chills, body aches, sore throat), had exposure to someone exhibiting COVID-19 symptoms or confirmed illness within the last 14 days, or have you traveled?
I have read this release form and confirm that all the information I have given is correct. I understand that this is a release form and I agree to be legally bound by it.
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
Phone #:*
Email:*
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.