Body Piercing-Minor Release Form

Ask a staff member what to enter
Today's Date:
Tue Oct 27 2020 02:58
Practioner:*
Name of Piercing:*
Location on the Body:*
Dead Rockstar Minor Body Piercing Consent Form
Please read and answer
Age*
I have been truthful in representing my age as a minor being under 18 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 except all risks that may arise from piercing. I also understand that each person reacts 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 this procedure. If a different piece of jewelry is needed during the healing process 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 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’s 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’ve been given the opportunity to ask questions and they have been answered to my satisfaction. I understand that I am signing a legal document.
Attorney Fees*
I agree to reimburse both the body piercer and Dead Rockstar for any attorneys fees and costs incurred in any legal action I bring against either the Body piercer and/ or Dead Rockstar and in which either the Body Piercer or Dead Rockstar is the prevailing party. I agree that the courts of Cass County, ND 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*
I agree 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 COVID-19 pandemic and will not hold Dead Rockstar responsible for any illness resulting from or related to the COVID-19 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/STI‘s? It’s OK if you do we just want to know for our and others 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 any other medical or skin condition 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 judgment and 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?*
 

In the following ID section please include a picture of parent/guardian ID, minor child
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 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:*
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


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