CONSENT TO PIERCING PROCEDURE
Let us do this part
Mon Oct 2 2023 05:58
Please read and answer
What piercing did you come in for today?
-- Select --
Ashley (Inverse Vertical Labret)
Dangerous Things xNT Implant
Jewelry Maintenance / Removal / Insertion
Navel (Belly Button)
Check after reading all conditions
I am not sick. I am not pregnant or nursing. If I have any conditions that might affect the healing of this piercing or my health, I will inform my piercer.
I have advised the piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible 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 trustfully represented to the piercer and staff that 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 non representation has been made to me as to the ability to later restore the skin involved in this piercing to it's pre-pierced 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 pierced using appropriately sterilized jewelry and instruments.
Legal Statement on Providing Documentation for Procedures.
I agree that all information and identification provided is valid and legal. I am providing a picture of my own identification. Any minors being pierced are being accompanied by their full legal parent or guardian. I will not falsify any information on this form; falsifying any information on this form or accompanying a minor for a piercing illegally will result in prosecution to the fullest extent of the law.
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Assumption of Risks: Participation in any procedure carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one procedure to another, but the risks range from minor scarring to infection. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in my procedure. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Holey Truth Body Arts LLC and it's operators HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in the procedure and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Pennsylvania and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
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.
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Date of birth:
You must be 18 or older
Sign above or type signature:
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.
This form is for client's 18 and older. If you are reading this message, go back to the list of forms and choose 'Piercing for Minors'. Thanks!
Guardian's Legal Name:
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
Please take photo(s) of your government issued photo IDs and related paperwork.