←
Drift piercing studios
Let us do this part
Today's Date:
Sun Oct 6 2024 09:25
Practitioner:
*
-- Select --
Jake
Lily
Ray
Rodman
Other
Body Piercing Location:
*
Body Piercing Price:
*
jewelry used :
*
Artist signature:
*
Welcome to Drift !
Please read and answer
Allergies
*
I have advised the Piercer of any allergies to metals, latex gloves, soaps, iodine, and/or medications. Please input the allergy you have in the text field. If you have no allergies, please type in N/A. I understand Drift piercing studios is not responsible for any reactions to materials if they are not listed here before hand.
Y
N
Eaten
*
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.
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 Drift piercing studios 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 Drift piercing studios, 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 given me 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.
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.
Emergency Contact
*
Please give a name address and phone number for an emergency contact.
Doctor
*
Please give the name, address, and phone number of your primary physician
No Refund Policy
*
I understand that checking this box that all jewelry sales are final and may not be refunded or returned. under any circumstances.
Metals and Alloys
I understand that Drift piercing studios never uses any jewelry containing nickel content for initial piercing. I understand that that Drift piercing studios only uses the following metals and alloys for initial piercing - Implant grade steel & titanium, 14k gold yellow, rose, and white. our white gold is allowed with palladium a well known hypoallergenic metal. if I am known to be allergic to any of these materials I assure that I have listed in the known allergen box.
No Doctor
I affirm that I do not have a primary care physician. If I require medical care I will taken to the nearest Emergency Room: Advent Health, 601 E Rollins St, Orlando FL, 407-303-5600
Complications
If the client has any complications, the piercer needs to describe the incident and how it was handled below
Gender/Sex
*
-- Select --
Prefer Not to Say
Male
Female
Race/Ethnicity
*
-- Select --
Prefer Not to Say
White/Caucasian
African American
Hispanic/Latino
Asian American
Native American
Other
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:
*
-Month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Day-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-Year-
1914
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
If you are under
18
your parent/guardian will be required
Phone #:
*
Email:
*
Sign up for our newsletter
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:
*
Photo ID
*
Please take photo(s) of your government issued photo IDs and related paperwork.
Remove Photo