Body Piercing Release Form
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Fri Oct 22 2021 04:24
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Location on the body:
Cost of piercing service:
Cost of jewelry selected:
Consent to pierce and release of liability
Please read and answer
I will notify a staff member immediately if I have a fever, flu-like symptoms, or shortness of breath.
By signing this consent and release, I acknowledge I have been given a full opportunity to ask any and all questions I have about the piercing procedure and the matters stated below, and all such questions have been answered to my satisfaction.
Are you under 18 years old?
I agree to show written proof of my age upon the request of the piercer.*
*If you are a minor (under the age of 18), your parent or legal guardian must consent in writing below and be present for the piercing procedure.
California Health & Safety Code Section 119302(b) and California Penal Code Section 652: The piercer may refuse to perform body piercing on a minor, regardless of parental or guardian consent pursuant to California Health & Safety Code Section 119302(e).
Alcohol & Drug Use
I attest I am not under the influence of alcohol or recreational drugs.
Fainting & Dizziness
Eating a meal or snack thirty minutes to an hour prior to the procedure as well as drinking plenty of fluids can help avoid dizziness or fainting.
I agree to IMMEDIATELY notify the piercer if I feel lightheaded, dizzy, and/or if I have a history of fainting.
Pregnant / Nursing
I attest I am not pregnant or nursing.
Do you have skin conditions that might interfere with the procedure or affect the healing of this piercing including, but not limited to, keloid or hypertrophic scarring, psoriasis, open wounds, or lesions at the site of the piercing.
Do you suffer from any medical conditions that might interfere with the procedure or affect the healing of this piercing including, but not limited to, diabetes, epilepsy, hemophilia, or a heart condition, or take prescription blood-thinning medications?
Do you have a history of, or are currently required to take prescribed antibiotics or other medications prior to dental or surgical procedures?
I attest I am not the recipient of an organ or bone marrow transplant, or if I am, I attest I have taken the prescribed preventive regimen of antibiotics recommended by my doctor in advance of this invasive procedure.
Do you have any chemical allergies? Examples can include metals, soaps, and medications (including iodine.)
Please verbally inform your piercer if you have any allergies.
I understand I will be pierced using appropriate instruments and sterilization.
[We clean and disinfect our customers’ skin with Povidone-Iodine antiseptic and alcohol. If you are allergic to iodine, we can use an alternative method of disinfecting your skin.]
Permanent Change & Scarring
I understand this piercing will result in a permanent change to my appearance and that no one from Lemonade Piercing has represented any ability to restore the piercing site and the surrounding skin and tissue to its pre-piercing condition even if the piercing is removed.
There are certain risks associated with body piercing. I understand these risks include, but are not limited to, temporary irritation, bubbles, lumps, infection, allergic reaction (e.g. to jewelry, cleanser), hyper granulation (bump), hypertrophic scarring (raised scar), keloid scarring (outward growing bump), atrophic scarring (sunken scar), nerve damage, chronic pain, migration of jewelry under the skin, rejection of jewelry, gum line recession/chipped teeth (tongue piercing), and damage to/destruction of/theft of my clothing during the piercing procedure. Having been informed of the risks associated with body piercing, both those known and unknown, I assume all said risks and wish to proceed with the piercing
I have received aftercare instructions, and to ensure proper healing of my piercing, I agree to follow the suggestions outlined in the written instructions until healing is complete. I hereby assume full responsibility for my aftercare and hygiene. I understand that activities like swimming during the initial healing time can put me at risk of infection.
NOT Medical Professionals
I understand that neither the piercer nor any other employee, agent, or independent contractor of Lemonade Piercing is a medical professional. None of them acts or can act in the capacity of one.
I attest I am voluntarily submitting to the piercing procedure without duress. I understand I am entering into a legally binding contract by inputing my signature below.
Release and Indemnity Agreement
In consideration for my piercing, I agree to defend, indemnify and hold harmless Lemonade Piercing and its agents, owners, employees, and independent contractors of and from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to my piercing including, but not limited to, those risks set forth in sections above, whether asserted by me or any third party who may be injured on account of or in any way related to my piercing, including, but not limited to, the procedure, conduct, and/or materials used. I further expressly agree that the foregoing release and indemnity agreement is intended to be as broad and inclusive as the State of California will allow and that if any portion thereof is held invalid, I agree that the balance shall continue in full legal force and effect.
I agree that the foregoing release and indemnity agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, and assigns, in the event of my death. By signing this agreement, I waive my right both now and any time in the future to bring a court action to recover compensation or obtain any remedy for any injury to myself or my property arising from the negligence or fault of Lemonade Piercing and its agents, owners, employees, and independent contractors, including but not limited to infection, virus transmission, illness, scarring, rejection and/or migration of jewelry, and/or any other injury or damage to personal property directly or indirectly caused by the negligence or fault of Lemonade Piercing and its agents, owners, employees, and independent contractors.
Attorney’s Fees and Costs
I understand that in the event of litigation relating to the subject matter of this agreement or to seek payment for services rendered, the prevailing party shall be entitled to receive from the other party his/her/their reasonable attorneys' fees and costs.
Permission to Photograph
I hereby irrevocably grant to Lemonade Piercing and its employees, owners, agents, and independent contractors the right to take photographs of the piercing performed by said grantees, and I understand that the photographs, whether in paper or electronic form, are the exclusive property of Lemonade Piercing, and I freely release any and all rights, title, or interest in them. I further grant to Lemonade Piercing and its employees, owners, agents, and independent contractors the right to use said images, in their sole discretion, for advertising or other commercial purposes.
I hereby release Lemonade Piercing and its employees, principals, agents, and independent contractors from any claims, legal actions, or other demands that may arise regarding the use of said photographs of my piercing.
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DECLARATION AND SIGNATURE
I hereby declare that I have read and understood the foregoing provisions, I agree to said terms and conditions, and I wish to proceed with the body piercing stated on page one of this agreement.
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.
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.
Date of birth:
If you are under
your parent/guardian will be required
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Sign above or type signature:
I, as parent or legal guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this release form
Guardian's Legal Name:
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
Please take photo(s) of your government issued photo IDs and related paperwork.