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Body Piercing Release Form

Let us do this part
Today's Date:
Sat Jun 14 2025 01:56
Practitioner:*
Body Piercing Location:*
Price:*
Jewelry Size & Material:*
Jewelry Vendor:*
Paramount Tattoo & Piercing
1020 W. Magnolia Ave.
Fort Worth, TX 76013
(817) 876-2499
paramount-tattoo.com
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.
Please read and answer
Y
N
Blood Sugar*
Have you eaten within the last 4 hours?
(Eating is recommended!)
Y
N
Pregnancy*
Are you pregnant? (If so, please alert your piercer!)
Y
N
Breastfeeding*
Are you breastfeeding? (If so, please alert your piercer!)
Y
N
Latex Allergy*
Are you allergic to latex? (If so, please alert your piercer!)
Y
N
Iodine Allergy*
Are you allergic to iodine or shellfish? (If so, please alert your piercer!)
Y
N
Blood Thinners*
Are you currently or have recently taken blood thinning medication? (If so, please alert your piercer!)
Y
N
Diabetes*
Do you have diabetes? (If so, please alert your piercer!)
Y
N
Epilepsy*
Are you Epileptic? (If so, please alert your piercer!)
Y
N
Heart Conditions*
Do you have any heart conditions? (If so, please alert your piercer!)
Y
N
Autoimmune Disorders*
Do you have any autoimmune disorders?
(IE: HIV/ AIDS, Hep A, Hep B, Hep C, etc. — If so, please alert your piercer!)
Y
N
Do you have any Flu-like symptoms?*
- A fever
- Flu-like symptoms
- Shortness of breath
(If so, please alert your piercer!)
Y
N
Covid-19*
Have you been exposed to Covid-19 or tested positive within the past 2 weeks? (If so, please alert your piercer!)
Infection *
I acknowledge that infection is always a possibility, particularly in the event that I do not properly take care of my piercing(s) and in no way do I hold Paramount Tattoo & Piercing liable for any problems or expenses that may occur if an infection or any complications arise.
Consent*
I acknowledge that the obtaining of my piercing is my choice alone, and I consent to the application of the piercing.
Permanent Change*
I acknowledge there is a risk or possibility of discomfort, pain, scarring, bleeding, swelling, infection and nerve damage. I agree for myself, my heirs, assigns and legal representatives to release and forever hold harmless Paramount Tattoo & Piercing from any and all claims, damages or legal actions arising from or connected in any way with the body piercing, procedures and conduct used to apply my body piercing.
Duress*
I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.
Downsizing*
I affirm that if my piercing requires downsizing of jewelry that I will do so during the appropriate time period or else I may experience complications due to neglect of aftercare, and Paramount Tattoo & Piercing will not be financially responsible for troubleshooting any issues that may arise.

Downsizing of jewelry size is required for specific piercings in order to stabilize the piercing to prevent migration.
Adolescent Risk*
I acknowledge there is an increased risk for adolescents during certain stages of development.
Questions*
I acknowledge that I have been given the full opportunity to ask any and all questions I may have about the obtaining of a body piercing from Paramount Tattoo & Piercing and all of my questions have been answered to my full and total satisfaction.
Waive*
I acknowledge that the obtaining of my body piercing is my choice alone and I consent to the application of the body piercing and to any actions or conduct of the associates, agents or representatives of Randy Adams Tattoo Studio, Inc. that are reasonable necessary to perform the body piercing procedure.

I agree to release and forever discharge and forever hold harmless Paramount Tattoo & Piercing and its associates, agents officers and shareholders from any and all claims, damages, or legal actions arising from or connected in any way with my body piercing or the procedures and conduct used to apply my body piercing and any and all body piercings applied by Paramount Tattoo & Piercing and its associates, agents and representatives in the future.
Legal Action*
I agree to reimburse each of the Artist and Paramount Tattoo & Piercing for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or Paramount Tattoo & Piercing and in which either the Artist or Paramount Tattoo & Piercing is the prevailing party. I agree that the courts of Texas in Tarrant County 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.
This Document*
I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.
Photography*
I give permission to use of my photos for the purpose of marketing. My pictures may appear in print or online. I hereby grant the Paramount Tattoo & Piercing permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.
*
I understand that the Return Policy states that all sales are final on all services and products. There are no exchanges or returns will be accepted, and refunds will not be issued.
 
How did you hear about us?
 
Written Care Instructions*
I have received a copy of applicable written care instructions, and I have read and understand such written care instructions.
An artist may not perform body piercing on a person younger than 18 years of age without the consent of a parent, managing conservator, or guardian and meeting the requirements of 25 Texas Administrative Code, §229.406(e).

The client shall consult a health care practitioner at the first sign of infection or an allergic reaction, and report any diagnosed infection, allergic reaction, or adverse reaction resulting from the body piercing to the artist and to the Texas Department of State Health Services, Tattoo and Body Piercing Program, at (512) 834-6711.
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.
Name:*
Address:*
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Gender:
Phone #:*
Email:*
Signature:*