Body Piercing Release Form
Ask a staff member what to enter
Today's Date:
Tue May 18 2021 06:25
Practioner:*
Piercing Area:*
Piercing Price:*
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.
Please read and answer
 
How did you hear about us?
 

Y
N
Do you have Flu like symptoms?*
IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.
Y
N
Diabetes*
Are you a diabetic? If so, please immediately inform your technician so we can discuss differences in healing.
Y
N
Anemia*
Do you suffer from anemia or low iron? It is important for the healing of your piercing, especially in low circulation areas like cartilage.
Y
N
Eaten*
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels. By hitting NO to this, you are affirming that you take full responsibility for your dietary intake and it's effect on your well-being.
Y
N
Bloodbourne Pathogens*
Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety).
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.
Release*
TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist 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*
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 the they have been answered to my total satisfaction.
Aftercare*
I affirm that I have been given the 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, 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.
Attorney Fees*
I agree to reimburse each of the Artist and the Piercing Studio for any attorneys. fees and costs incurred in any legal action I bring against either the Artist or the Piercing Studio and in which either the Artist or the Piercing Studio is the prevailing party. I agree that the courts of WA in Australia 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.
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.
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:
Preferred name:
Address:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:
Email:*
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Social Handle:
If you don't mind us tagging you in photos online
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #: