Body Piercing

Ask a staff member what to enter

Today's Date:

Wed May 15 2024 11:47

Practitioner:*

Body Piercing (include side of body if applicable):*

Please read and answer

How did you hear about us?

Eaten*

Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.

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 instructions have been made available on the care of my piercing while it is 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 that the courts of Muncie, Indiana 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.

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.

Black Sword Alliance (“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.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering the Facility and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Facility may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Facility employees, contractors, representatives.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with being in the Facility and/or receiving services (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless the Facility, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Facility, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after receiving services within the facility.

To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facilitie’s guidelines. The facility’s guidelines can be changed at anytime as new information and technology become available.

I confirm that I am not presenting any of the symptoms of COVID-19 including dry cough running nose, sore throat, shortness of breath, loss of sense of taste or smell, or fever.

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have not traveled outside of or domestically within the ?USA in the past 14 days.

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:*

Chosen name:

Address:

Postcode:

Date of birth:*

If you are under 18 your parent/guardian will be required

Phone #:*

Email:*

Signature:*

Sign above or type 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.