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Body Piercing
Let us do this part
Today's Date:
Sat May 2 2026 07:12
Practitioner:*
Please read and answer
I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I may have about obtaining a piercing by MARAH LANDRY and all questions have been answered to my full and total satisfaction.
 
Y
N
I do not have diabetes, epilepsy, hemophilia, nor do I have a heart condition or take blood thinning medication. I do not have any other medical/skin condition that may interfere with the procedure or healing of the piercing. I am not pregnant or nursing.
Y
N
If I have HIV, Hepatitis, AIDS or any other communicable diseases, I have made the appropriate staff member aware.
Y
N
I have eaten within the last 4 hours before my piercing to help avoid any sort of blood sugar drop.
Y
N
I have been fully informed of the risk, associated with getting a piercing. I understand that these risks can lead to injury, including but not limited to infection, scarring/keloiding and allergic reactions. I accept all risks that may arise from my piercing.

I have informed the appropriate staff member if I have any allergies to latex, metals, soaps or medications.
Y
N
I affirm that I am NOT under the influence of alcohol and/or drugs, and I am voluntarily getting a piercing.
Y
N
I acknowledge that my piercing may result in a permanent change to my body and that my skin may not be restored to its pre-piercing condition even after its removal.
Y
N
I give consent in advance to have my photograph taken and the potential reproduction in print or electronic form.
Y
N
I agree to waive and release to the fullest extent permitted by law MARAH LANDRY and PHENIX SALON SUITES from all liability whatsoever, for any and all claims/causes of action that I, my estate, heirs, executors or assigns may have for personal injury and/or damages, whether caused by the negligence or fault of either MARAH LANDRY or PHENIX SALON SUITES, or otherwise.
 
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:*
Pronouns:
Chosen name:
Address:*
Postcode:*
Date of birth:*
 
If you are under 18 your parent/guardian will be required
Age: 
Phone #:*
Email:*
Signature:*

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