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The Powers That Be Piercing Waiver

Let us do this part
Today's Date:
Fri Apr 19 2024 02:06
Please read and answer
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By checking this box, you confirm that you have not been sick or come into contact with anyone that has been sick in the past 7 days, including covid-19 symptoms: dry cough, sore throat, runny nose, shortness of breath, fever, loss of taste or smell.
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By checking this box, you affirm that you are voluntarily getting this piercing and you are healthy and willing to follow your piercer’s recommendations for healing.
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By checking this box, you affirm that you are not under the influence of alcohol or drugs.
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By checking this box, you agree to release the piercer and The Powers That Be from all liabilities.
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You acknowledge that your piercer is not a medical professional and their advice does not replace advice from a medical professional.
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You will be pierced using aseptic technique, with sterilized equipment and jewelry. You acknowledge that infections typically occur due to external variables that are your responsibility.
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You acknowledge that this piercing may leave noticeable, permanent scarring.
Y
N
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Do you have any allergies?
Y
N
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Do you have diabetes, epilepsy, hemophilia, a heart condition, or are you taking blood thinning medication?
Y
N
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Do you have a medical or skin condition that may interfere with the healing of your piercing?
Y
N
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Are you pregnant or nursing?
Y
N
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Do you consent to having photos taken that we may use on our website or social media?
 
Here's where you can add any additional info pertaining to the questions above:
 
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:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


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