Body Piercing Release Form

Ask a staff member what to enter
Today's Date:
Tue Oct 27 2020 04:14
Practioner:*
Name Of Piercing:*
Location On The Body:*
Dead Rockstar Body Piercing Consent Form
Please read and answer
Age*
I have been truthful in representing my age as at least 18 (eighteen) years of age to the associates, agents, employees, and representatives of Dead Rockstar. If I have knowingly misrepresented my age and/or identity Dead Rockstar may prosecute me to the fullest extent of the law.
Duress*
I acknowledge that I am not under the influence of alcohol, drugs, or any controlled substance and it is my choice alone to which I consent to the body piercing and to any procedures, conduct, and/or actions that take place to perform the procedure.
Risks*
I understand that there are risks, known and unknown, which can lead to injury, including but not limited to infection, scarring, and allergic reactions. 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 that may arise from piercing. I also understand that each person may react differently to the procedure and that neither the body piercer nor Dead Rockstar is responsible for excessive swelling, irritation, or any other complications that may arise from the procedure and if a different piece of jewelry is needed it will be at my expense. If I choose to seek medical attention it will be at my own expense.
Permanent Change*
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.
Jewelry Variation
I understand that there may be variations in color between the body jewelry in the showcase and the actual body jewelry used in my body piercing.
Aftercare*
I have been given instructions on the care of my piercing while it is healing and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions.
Questions*
I acknowledge that I have been given adequate opportunity to read and understand this document and that it was not presented to me at the last minute. I have been given the opportunity to ask questions and they have been answered to my satisfaction. I understand that I am signing a legal contract.
Attorney Fees*
I agree to reimburse both the body piercer and Dead Rockstar for any and all attorney's fees and costs incurred in any legal action I bring against either the body piercer and/or the Dead Rockstar and in which either the body piercer or Dead Rockstar is the prevailing party. I agree that the that the courts of Cass County, North Dakota shall have 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.
Release*
TO WAIVE AND RELEASE to the fullest extent permitted by law the body piercer and Dead Rockstar 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 body piercer and/or Dead Rockstar, or otherwise.
COVID-19*
I understand that it is at my own risk to receive services from Dead Rockstar during the COVID19 pandemic and will not hold Dead Rockstar responsible for any illness resulting from or related to the COVID19 pandemic nor will I take any legal action.
Y
N
COVID-19*
Have you had contact with anyone with confirmed COVID-19 in the last 14 days? Do you have any of the following symptoms: fever (100.4 or higher), chills, repeated shaking with chills, cough, headache, shortness of breath (not severe), muscle pain, sore throat, or new loss of taste or smell? If yes please provide details.
Details:
 

Y
N
Bloodbourne Pathogens*
Do you have any communicable diseases such as Hepatitis A, B, or C, HIV, AIDS, or contagious diseases such as Tuberculosis, Mononucleosis, Pneumonia, or STDs/STIs? (It's okay of you do, we just want to know for our and other's safety). If yes please provide details.
Details:
 

Y
N
Allergies*
Are you allergic to nickel, iodine, latex or anything else that could cause skin rash, anaphylactic shock, or requires immediate medical attention? If yes please provide details.
Details:
 

Y
N
Medical Conditions*
Do you have any of the following: diabetes, epilepsy, hemophilia, a heart condition or take blood thinning medication? Do you have other medical or skin conditions that may interfere with the procedure or healing of the piercing? Are you a recipient of an organ or bone marrow transplant and, if you are, have you taken the prescribed preventive regimen of anti-biotics that is required by your doctor in advance of any invasive procedure such as piercing. Are you pregnant or breastfeeding? Do you have a mental impairment that may affect your judgement in getting the piercing? If yes please provide details.
Details:
 

Y
N
Photography*
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. If you check no please let your body piercer know.
 
How did you hear about us?*
 

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.
Personal Info
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Name:*
Address:*
Date of birth:*
You must be 18 or older
Phone #:*
Email:*
Social Handle:
If you don't mind us tagging you in photos online
Signature:*


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