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Hummingbird Jewelry Change Release Form

Let us do this part

Today's Date:

Fri Nov 21 2025 04:29

Practitioner:*

Body Piercing Location:*

Please read and answer

Do you have Flu like symptoms?*

IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

How did you hear about us?

Bloodbourne Pathogens*

Do you have any bloodborne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety).

Risks*

I understand that there are risks involved in changing a piercing, especially a healing 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 receiving a jewelry change, I still wish to proceed with the jewelry change and I freely accept all risks that may arise.

Release*

agree TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artists and Hummingbird Piercing, LLC 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 Hummingbird Piercing, LLC, 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 jewelry change procedure and the they have been answered to my total satisfaction.

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.

Medical Conditions*

Are you pregnant or nursing?

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.

Legal*

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 courts of California in The United States of America 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. Furthermore, I understand that any and all information whether verbally or in this release form, does not constitute any liability or responsibility on the part of Hummingbird Piercing, its employees, principles, agents, and/or affiliates and that Hummingbird Piercing, its employees, principles, agents, and/or affiliates are not medical doctors, nor do they imply or suggest to be and offer no information as a replacement of that of a medical doctor.

Legal*

understand that all jewelry installed by Hummingbird Piercing comes with a manufacturers warranty, and will be replaced or repaired at no cost due to any manufacturing defects. I understand that if a piece of jewelry installed by Hummingbird Piercing falls out within two (2) weeks of being installed, Hummingbird will replace this piece of jewelry. Any longer than two weeks, it becomes my responsibility.

Photography of Piercings and Jewelry

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.

Allergies*

Do you have any allergies to medications or antiseptics such as iodine or chloroxylenol?

Details:

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:*

Sign above or type signature:

Photo ID

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