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Jewelry Change/Check-Up/Consultation

Let us do this part
Today's Date:
Wed May 8 2024 04:44
I request BODY PIERCING BY BINK, LLC to assist me with my body piercing.
By completing and signing this form, I hereby release BODY PIERCING BY BINK, LLC, its employees, and agents from all manner of liabilities, claims, actions, or demands, in law or in equity, which I or my heirs might have now or hereafter, by complying with my request for said procedure.
Please read and answer
 
Which piercing(s) are we assisting with today?
 
Y
N
Would you like to be enrolled in our Loyalty Program? It's free and we won't spam you!
Choose "yes" if you would like to be enrolled, or if you believe you are already enrolled. You will receive a text when you enroll and when new rewards are available to you. Each dollar spent is a point earned; points are redeemable for a variety of rewards. Rewards may expire but points do not.
Y
N
Would you allow us to photograph your piercing today?
Please specify below if you would allow us to use these photographs below for our personal portfolios, social media accounts, or both. If you would like to be tagged in our social media posts, please use the box below to enter any social media handles!
Details:
 
I understand that I may have a copy of this statement if I request it. I certify under Penalty of Perjury that all included information is true and correct.
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.
Legal Name:*
Pronoun:
Chosen name:
Address:*
Postcode:*
Date of birth:*
Phone #:*
Email:
Signature:*


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