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Minor Piercing Release Form

Let us do this part
Today's Date:
Fri May 9 2025 12:11
Practitioner:*
Parent/Guardian Name:*
Please read and answer
*
I acknowledge by signing this release I have been given the full opportunity to ask any and all
questions which I might have about obtaining from a service provider and all my questions
have been answered to my full and total satisfaction. I acknowledge I have been
advised of the matters set forth below and agree as follows:
*
I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from
any heart conditions or take medication which thins the blood. I have informed my piercing
of any condition such as diabetes that might hamper healing of the piercing.
*
If I suffer from hepatitis, or any other communicable disease, I have informed the Piercer
of this fact and I have been advised of any procedure necessary to promote
the satisfactory healing of my piercing.
*
I do not suffer from medical of skin conditions such as, but not limited to, keloid or
hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions
at the site of the piercing.
*
I have advised the Piercer of any allergies to metals, latex gloves (we are a latex
free studio), soaps and medications. I acknowledge it is not reasonably possibly for the
Piercer to determine whether I might have an allergic reaction to the piercing
or processes involved in the piercing and further acknowledge that such a reaction is possible.
*
I have trust fully represented to the Piercer I am over the age of 18 years. I am not under
the influence of drugs or alcohol. To my knowledge, I do not have any physical,
mental or medical impairment or disability which might affect my well-being as a direct
or indirect result of my decision to have a piercing done at this time.
*
I acknowledge that obtaining this piercing is my choice alone and will result in a permanent
change to my appearance, and that no representation has been made to me
as to the ability to later restore the skin involved in this piercing to its pre-piercing condition.
*
I acknowledge infection is always possible as a result of obtaining a piercing. I have
received aftercare instructions and I agree to follow all of them while my piercing is healing.
*
I understand I will be piercing using appropriate instruments and sterilization
I hearby consent to possible procedural viewing and/or authorize the use and reproduction
of any and all procedure photographs without compensation to me or anyone associated
with me. All photographs, negatives, positives, slides, computer images, and/or video
footage being the sole property of Born This Way Body Arts.
*
I, the undersigned, certify that I am the parent, legal guardian, or legal custodian of the named minor and further give consent to the body piercing procedure(s) as explained. I acknowledge that I am fully aware that to falsify my legal standing as to being the minor’s parent, legal guardian or legal custodian constitutes a class C misdemeanor. A class C misdemeanor means imprisonment for not greater than thirty (30) days or a fine not to exceed fifty dollars ($50) or both. (TCA 40-35-111)
*
I understand this type of piercing usually
takes 6 months or longer to fully heal. I agree to release and forever discharge and hold
harmless the Piercer and all employees from any and all claims, damages or legal actions
arising from or connected in any way with my piercing, or the procedure and conduct
used in my piercing.
Y
N
*
Have you been told to quarantine/isolate by a health care provider or the health department?
Have you have face-to-face contact for 10 or more minutes with someone who has had COVID-19?
Are you currently:
Experiencing a fever?
Cough, shortness of breath?
New loss of sense of taste/smell?
Vomiting or diarrhea within the past 24 hours?
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.
Name:*
Address:
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


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