Body Piercing/Jewelry Change Release Form
Let us do this part
Today's Date:
Wed Jun 16 2021 11:57
DO NOT FILL OUT THIS FORM UNLESS YOU HAVE ALREADY BOOKED AN APPOINTMENT. FILLING OUT THIS FORM IS NOT THE WAY TO BOOK AN APPOINTMENT.

BY SIGNING THIS LEGAL DOCUMENT, YOU AGREE TO WAIVE CERTAIN LEGAL RIGHTS INCLUDING THE RIGHT TO SUE FOR INJURIES OR DAMAGES. PLEASE READ CAREFULLY.

1. DISCLAIMER SKIN DECISION (the “Business”) is not responsible for any death, injury, loss or damage of any kind suffered by any person while participating in the Services of PIERCING, JEWELRY CHANGES, CHECKUPS, TATTOOS, OR MICROBLADING (the “Services”), caused in any manner whatsoever including, but not limited to, the negligence of the Business. I agree that this Agreement shall apply to all future services or products purchased from the Business.

2. DESCRIPTION OF RISKS – In consideration of my being permitted to participate in the Services, I hereby acknowledge that I am aware of the risks associated with or related to the Services and the use of any supplies or equipment in the Services, as applicable, which include but are not limited to:

RiskI9 of Exposure to COVID-19. By engaging in these Services, I agree to fully accept all known and unknown risks, including the potential risk of exposure to respiratory illnesses or other illnesses, diseases, or conditions, including but not limited to, the novel coronavirus known as COVID-19 (“COVID-19”). COVID-19 can be transmitted via exhaled respiratory droplets, most often through coughing, sneezing and breathing in close proximity to another person. Although the Service Provider is complying with all applicable provincial and federal laws, and applicable public health orders and guidelines regarding cleaning, disinfecting and practices which reduce the potential for exposure to COVID-19, I understand that I may be exposed to COVID-19 or its symptoms despite all compliance and best efforts of the Service Provider. I understand and agree to hold the Service Provider harmless and not liable for any symptoms of COVID-19 or any other disease, illness, or condition, nor for exacerbating any existing symptoms of any illness, disease or condition, and I agree to accept these and all other known and unknown risks of receiving Services from the Service Provider.

Other complications may include scarring, infection, allergic reaction or rejection of the piercing or tattoo ink. I understand that by having this service performed, I am making a permanent change to my body and no claims have been made regarding the ability to undo any changes made.



3. FITNESS TO PARTICIPATE – I agree that I am in good health, and in proper physical condition to participate in ALL of the Services and am NOT under the influence of alcohol, illicit or prescription drugs that would in any way impair their ability to safely participate in the Services and do NOT have ANY preexisting conditions which would make me unfit to participate in ANY of the Services. I agree that it is my sole responsibility to determine the sufficiency of my health, fitness, and ability to participate in ANY of the Services provided by the Business.

I understand that I will be serviced using appropriate instruments and techniques. To ensure proper healing of my piercing, I agree to follow the aftercare guidelines that have been provided in the aftercare pamphlet until healing is complete.

4. RECORDING CONSENT AND RELEASE – I hereby give the Business exclusive rights and permissions to photograph and record me in any video, audio or digital format. I understand and consent to this material to be used by the Business for marketing and promotional purposes without further consent or release from me.

5. ACKNOWLEDGMENT OF THE RULES – I agree that I MUST read, understand and follow all rules provided by the Business. By signing this Agreement, I represent and warrant that I have READ, UNDERSTAND and WILL FOLLOW ALL RULES and acknowledge that failure to do so may result in an increased risk of injury or illness.

6. RELEASE OF LIABILITY - In consideration of the Business allowing me to participate in the Services, I agree as follows:

a. To assume all risks arising out of, associated with or related to my participation in the Services, even though such risks may have been caused by the negligence of the Business;
b. To be solely responsible for any injury, loss or damage which I might sustain while participating in the Services, even though such injury, loss or damage may have been caused by the negligence of the Business;
c. To release the Business from liability for any and all claims, demands, actions and costs which might arise out of my participation in the Services, even though such claims, demands, actions and costs may have been caused by the negligence of the Business.

7. ACKNOWLEDGEMENT – I acknowledge that I have read this agreement, that I have executed this agreement voluntarily, and that this agreement is to be binding upon myself, my heirs, executors, administrators and representatives.

Please read and answer
 
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Age:
 

 
If under 18, parent's #ID:
 

 
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Name of the piercing (or body part):
 

 
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Date of piercing/jewelry change appointment:
 

Y
N
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Have you ever fainted?
Y
N
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Have you noticed that you are prone to heavy bleeding?
Y
N
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Have you taken any of the following in the last 24 hours: Accutane, aspirin, ginseng, ibuprofen, chemotherapy drugs or immunosuppressants?
Y
N
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Are you allergic to latex, dye, metal, soaps, other?
Details:
 

Y
N
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Do you require antibiotics before dental work or any other medical procedures?
Y
N
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Do you have any other conditions that may affect the procedure or healing of your piercing? (Including: diabetes, anemia, keloids, skin infections, HIV, hemophilia, hepatitis, epilepsy, tuberculosis, pregnancy, breast feeding, or other)
Details:
 

Y
N
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Have you consumed any drugs or alcohol in the last 24 hours?
Y
N
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Do you consent to release any photos we may take for our use in advertising and publication?
Y
N
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Do you understand that your piercing may require downsizing, in which you will be responsible for the cost of the new piece of jewelry?
Y
N
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I and all in my household are free of symptoms of COVID-19.

Y
N
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Have you, or anyone in your household, travelled outside of Nova Scotia in the last 14 days? (Please answer honestly.
Travel within the Atlantic bubble will be permitted, except for in Orange/Red Zones.)
Y
N
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I will contact the studio if I develop symptoms of COVID-19 within the following 14 days, and I will contact 811.
Y
N
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I have read and agree to adhere to the studio's COVID-19 protocols, including not entering without an appointment, and wearing a mask while in the studio.
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.
Legal Name:*
Pronoun:
Preferred name:
Address:*
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
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Signature:*