Piercing

Let us do this part

Today's Date:

Wed May 8 2024 01:36

Practitioner:*

I am requesting the Piercer to perform the below stated piercing. I understand this type of piercing usually takes the stated amount of time OR LONGER to heal. I agree to release and forever discharge and hold harmless the Piercer and all employees from any and all claims, damages, or legal actions arising or connected in any way with my piercing, or the procedure and conduct used in my piercing. I have received both verbal and written education and information regarding my piercing. I understand that I may have a copy of this statement if I request it.

I specifically acknowledge that I have been advised of the matters set forth by Body Piercing by Bink (herein called "Piercer"), and agree as follows:

Photo ID*

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

Please read and answer

Which piercing(s) are we adorning today?*

Have you eaten in the past 3 hours?*

It is recommended that you have had something to eat or drink recently to reduce the risk of you feeling lightheaded or dizzy after your piercing.

Do you have any flu-like symptoms?*

Please notify a staff member if you have or have had in the past two weeks:

- loss of taste and/or smell
- a fever
- flu-like symptoms (coughing, sneezing, fatigue, etc)
- shortness of breath

Details:

Do you have upcoming travel plans in the next month?*

Piercings are more susceptible to issues when they’re new. Please let us know if your vacation plans will include submerging your piercing(s) in water, no access to a shower/clean running water, or plane travel.

Details:

I am not currently intoxicated and I do not have any physical, mental, or medical impairment which might affect my well-being as a direct or indirect result of my decision to get a piercing today.*

We use topical antiseptics such as alcohol swabs, iodine, and BZK to clean the area around your piercing. It is not possible for the Piercer to determine whether you might have an allergic reaction, and by continuing, you acknowledge that such a reaction is possible. Please inform us of any known topical allergy you may have.*

There are certain risks associated with getting a new piercing while pregnant or nursing. Please inform us if you are.*

Certain medical conditions and medicines may hinder successful healing of a new piercing. Please read and initial.*

Such conditions include but are not limited to: diabetes, MRSA, bleeding disorders, history of keloids, psoriasis or lesions at the site of the piercing. Medicines may include: blood thinners or Accutane. You may list any condition or medicine you wish to disclose in the box below, or discuss directly with your Piercer.

Understanding the Permanent Physical Change of a Piercing. Please read and initial.*

I acknowledge that obtaining a piercing is my choice alone and will result in a permanent change to my appearance, and that the skin involved in the piercing will not be restored to pre-piercing condition. I understand that even with optimal aftercare the piercing may incur complications and/or have to be removed. If I choose to seek piercing advice from a physician, the Piercer is not responsible for expenses acquired.

Understanding the Risks of receiving and healing a Piercing. Please read and initial.*

I acknowledge that infection and/or irritation of my piercing can result from environmental irritants and/or trauma. I understand it is my responsibility to follow aftercare instructions for my piercing and promptly seek guidance from the Piercer if I have any concerns.

Understanding the Jewelry & Procedure. Please read and initial.*

I understand I will be pierced using sterile instruments and jewelry, using aseptic technique compliant with Florida Statute 381.0075 & Rule Chapter 64E-19. The jewelry used for all initial piercings is medical implant quality (where applicable), or is comprised of an inert and biocompatible material.

Filming & Photography is NOT allowed. Please read and initial.*

I understand that filming and photography, by myself or my accompanying parties, is NOT ALLOWED during any procedure. Photos before and after the piercing are acceptable - and encouraged!

I have truthfully represented to the Piercer that I am over the age of 18 years OR have provided notarized parental consent.*

All people under the age of 18 must have their natural parent or legal guardian's consent on a notarized form from the Florida Department of Health. If you need a copy of this, please ask your Piercer.

Would you like to enroll in our Loyalty program for 10% off on your first visit? It is free and we won't spam you!*

Every dollar you spend will accumulate one point. You can trade in your accumulated points for rewards and discounts on future visits! You will receive a text when you enroll and when new rewards are available to you. Rewards may expire but points do not.

Would you allow us to photograph your piercing today?*

Please specify below if you would allow us to use these photographs 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:

How did you hear about us?

I certify under Penalty of Perjury that all included information is true and correct. I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I might have, and that all of my questions have been answered to my full and total satisfaction.

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:

Chosen 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:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:*

Physician Information

Enter your physician or medical practitioner's contact details or use our suggested default medical facility.

Name:

Contact:

Address: