←

Golden Laurel Piercing, LLC – English

Let us do this part
Today's Date:
Sat Aug 2 2025 11:29
Practitioner:*
Body Piercing Location:*
Please read and answer
*
I have been fully informed of the risks associated with getting a piercing. I understand that these risks can lead to complications, including but not limited to: infection, scarring, and allergic reactions (to jewelry, latex gloves, or other products). 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 and complications that may arise from the piercing.
*
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.
*
I affirm that I do not have diabetes, epilepsy, or hemophilia, nor do I have a heart condition. I do not take blood thinning medication.

I do not have any other medical or skin conditions 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 antibiotics that is required by my doctor prior to receiving any invasive procedure (such as a piercing).

I am not pregnant or nursing.
*
I affirm that I have been given instructions on the care of my piercing while it is healing, and I understand and will follow them.

I acknowledge that it is possible that the piercing can become infected or irritated, particularly if I do not follow the provided aftercare instructions.
*
I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.
*
I waive and release, to the fullest extent permitted by law, the practitioner and Golden Laurel Piercing, LLC (“GLP”) 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 practitioner or the piercing studio, or otherwise.
*
I agree to reimburse the practitioner and GLP for any attorney fees and costs incurred in any legal action I bring against either the practitioner or GLP, and in which either the practitioner or the studio is the prevailing party. I agree that the courts of Cumberland County and the State of Pennsylvania 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.
I release all rights to any photographs taken of me and the piercing, and I give consent in advance to their reproduction in print or electronic form.
*
I affirm that the practitioner and the studio have given me the full opportunity to ask any and all questions about the piercing procedure, and they have been answered to my total satisfaction.
*
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.
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.