Ask a staff member what to enter
Today's Date:
Fri Mar 29 2024 10:14
Practitioner:
*
-- Select --
Joeltron
Bree
Jackson
Anisah
Piercing Area:
*
Piercing Price:
*
Photo ID
*
Please take photo(s) of your government issued photo IDs and related paperwork.
Remove Photo
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 diabetic? If so, please immediately inform your technician so we can discuss differences in healing.
Y
N
Low Iron or Anaemia
*
Do you, or have you had, low iron or suffered from anemia? 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 4 hours? It's a good idea to increase your blood sugar levels before your piercing.
Y
N
Bloodborne Pathogens
*
Do you have any Bloodborne pathogens, transmittable diseases, or recent illnesses? (It's okay if you do, we just would like to know)
Y
N
Medical Conditions
*
Please select 'Y' if you have any of the following medical conditions:
epilepsy, haemophilia, a heart condition, are taking blood-thinning medications, or have any other medical or skin condition that
may interfere with the procedure or healing of the piercing. Additionally, please select 'Y' if
you are the recipient of an organ or bone marrow transplant, and you have not taken the prescribed preventative regimen of antibiotics that is
required by your doctor in advance of any invasive procedure such as piercing.
Details:
Recent Pregnancy
Please select if you are currently pregnant or if you have been breastfeeding/chestfeeding within the last 6 months.
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, 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 waive and release, to the fullest extent permitted by law, the practitioner and the piercing studio from all liability, and for any and all claims or causes of action that I, my estate, heirs, or executors, may have, for personal injury or otherwise. This includes any direct and/or consequential damages which result or arise, whether caused by the negligence or fault of either the practitioner or the piercing studio, or otherwise.
Questions
*
Both the practitioner and the piercing studio have given me the full opportunity to ask any and all questions about the piercing procedure, and these questions have been answered to my satisfaction.
Aftercare
*
I have been given the instructions on the care of my healing piercing, and I understand and agree to follow these instructions. I acknowledge that it is possible for the piercing to become infected, particularly if I do not follow the aftercare instructions.
Duress
*
I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.
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 the practitioner and the piercing studio for attorney's fees and costs incurred in any legal action I bring against either the practitioner or the piercing studio, and in which either the practitioner 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.
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:
-select-
He/Him
She/Her
They/Them
He/Them
She/Them
He/She
He/She/They
Chosen name:
Address:
Postcode:
Date of birth:
*
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If you are under
18
your parent/guardian will be required
Phone #:
Email:
*
Social Handle:
If you don't mind us tagging you in photos online
Signature:
*
Sign above or type signature:
Parent/Legal Guardian
I, as custodial parent or legal guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this release form and I attest that all documentation I have provided is true and accurate.
Guardian's Legal Name:
*
Relationship:
*
-select-
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
Signature:
*
Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #: