Irritated piercing jewellery removal

Let us do this part

Today's Date:

Sun Jul 13 2025 05:12

Practitioner:*

Piercing type/ body location:*

Date Piercing was performed :*

Description of irritation and procedure performed :*

This form is to retain information on the safe and professional removal of an irritated, embedded, rejecting, migrating or poorly performed piercing.

Please read and answer

Was this Piercing performed at another studio and/or piercer *

This is to clarify if your piercing was or was not performed by the same piercer or studio that will be undertaking the removal.

Removal procedure*

I have been fully informed of the type of removal procedure that may be required in order to safely and effectively remove the jewellery from my irritated, imbedded, rejecting or migrating piercing. I understand that the piercer performing the removal may need to use a needle to make a small incision if my jewellery has become imbedded or for the removal of a rejecting dermal or surface bar.

Risks*

That I have been fully informed of the risks, associated with getting a jewellery removal. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring and keloiding and allergic reactions. Having been informed of the potential risks associated with getting a removal, I still wish to proceed with the procedure and I freely accept all risks that may arise from the removal.

Eaten*

Have you eaten within the last 2 hours? It's a good idea to eat before hand to increase your blood sugar levels. If you have not eaten, your piercer may not be able to remove your jewellery.

Bloodbourne Pathogens*

Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for our and other's safety).

Release*

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Piercing Studio 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 Artist or the Piercing Studio, or otherwise.

Questions*

That both the Artist and the Piercing Studio have given me the full opportunity to ask any and all questions about the removal procedure and that they have been answered to my total satisfaction.

Aftercare*

I affirm that I have been given instructions on the care of my wound while its healing, and I understand them and will follow them. I acknowledge that it is possible that the wound can become infected, particularly if I do not follow the instructions. I agree that should I be concerned that I may have an infection, that I will seek out a medical practitioner immediately. I understand that the piercer that will be undertaking the removal will sufficiently clean and pack my piercing should it be necessary to do so.

Duress*

I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.

Medical Conditions and medications*

Do you have any medical conditions or take any medications that may interfere or prohibit the healing or cause further risks to yourself during the removal procedure, such as but not limited to diabetes, epilepsy, hemophilia, a heart condition, blood thinning medication or roaccutane. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as piercing. I am not pregnant or nursing.

Details:

Permanent change*

I acknowledge that the removal 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.

Attorney Fees*

I agree to reimburse each of the Artist and the Piercing Studio for any attorneys. fees and costs incurred in any legal action I bring against either the Artist or the Piercing Studio and in which either the Artist or the Piercing Studio is the prevailing party. I agree that the courts of Swansea in Wales shall have personal 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.

Photography*

I release all rights to any photographs taken of me and the removal and give consent in advance to their reproduction in print or electronic form.

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 16 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 #:

Photo ID*

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