Body Piercing Release Form
Let us do this part
Today's Date:
Tue Sep 22 2020 05:40
Body Piercing Location:*
Please read and answer
 
How did you hear about us?
I'm a regular Yelp Google Personal Referral Other

Release*
I HEREBY WAIVE, RELEASE, AND HOLD HARMLESS, to the fullest extent permitted by law, the facility Body Manipulations and its agents 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.
Risks*
I acknowledge that the piercing 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. I have been fully informed of the risks, associated with getting a piercing. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, keloiding, 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 accept all risks that may arise from piercing.
Healing Period*
I understand there is a healing period following the procedure and it is suggested to adhere to an aftercare regiment. Suggested aftercare procedures are included in the appropriate aftercare materials furnished post procedure. I understand infection can occur with or without proper hygiene.
Y
N
Wellness*
Do you have any of the following symptoms: fever, cough, shortness of breath, body aches?
Y
N
Eaten*
Have you eaten in the past 3 hrs?
Y
N
Alcohol*
Have you consumed alcohol within the last 12 hours?
Y
N
Blood*
Do you have any bleeding disorder, hemophilia, diabetes, or cardiac valve disease, any other heart condition, or taking any blood thinning medication?
Y
N
Pregnant*
Are you pregnant?
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.
Sound Mind*
I am fully aware and of sound mind to request this body art procedure and do not wish mutilation or harm upon myself.
This Form*
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 or under duress. I understand that I am signing a legal contract, and I agree to be legally bound by it.
Parents/Legal guardians must photograph their ID along with the above minor's birth certificate.
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:*
Prefered name:
Address:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Sign up for our newsletter
Signature:*


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