Piercing Release Form 2020 Release Form

Let us do this part
Today's Date:
Sun Nov 29 2020 09:40
Practioner:*
Piercing Release Form 2020
Please read and answer
***IMPORTANT READ AND BE CERTAIN TO UNDERSTAND THE IMPLICATION OF SIGNING*** ***INITIAL EACH PROVISION ON THE LINES PROVIDED AFTER READING TO SHOW THAT YOU UNDERSTAND EACH PROVISION***
***BY READING, SIGNING THE DOCUMENT, CLICKING THE CHECKBOXES, or ANSWERING BESIDE EACH PROVISION AFTER READING, YOU ACKNOWLEDGE THAT YOU UNDERSTAND EACH PROVISION AND AGREE TO THE POLICIES***
Health Risk Assessment (2020 revision)
Do you or does anyone in your household present with symptoms of any illness including; cough, fever, shortness of breath, runny nose, sore throat, nasal congestion, unexplained aches, vomiting, diarrhea, loss of smell or taste? If yes please reschedule your appointment, deposits will not be lost. We are also closely monitoring our staff for your safety. We appreciate your honesty.

Travel Contact
Have you travelled internationally or provincially (meaning out of province) in the last two weeks? If yes please reschedule your appointment, deposits will not be lost. If someone in your household travels as well we ask again you reschedule your appointment. Thank you, we appreciate your honesty.

Health Risk Assessment (revision 2020)
Have you attended any large gatherings of more than 15 people indoors,or more than 30 people outdoors? If yes, you MUST REBOOK your appointment. You MUST wait a minimum of 14 days from the event you attended before your appointment. This is per Saskatchewan Health Rules.
If you have been in any indoor settings with larger groups of people such as bars, pubs..etc where you cannot social distance or have been in without wearing a mask we ask that you wait 14 days and then re book. You MUST inform us before your appointment.

Health Risk Assessment 2020
I have read the above information and I understand and agree that the information I have provided above is accurate and realize that some of the conditions are subject to change based on the Saskatchewan Health guidelines.

Y
N
Health*
Do you have HIV, AIDS, Hepatitis (any strain) or any blood-borne illness?
Details:
 

Y
N
*
Have you been tested for any of the above? Include when you were last tested.
Details:
 

Y
N
*
Are you Pregnant or breastfeeding? If yes you cannot receive a tattoo or piercing.
Y
N
*
Do you have high blood pressure, diabetes, bleeding disorders, heart problems, cold/flu…etc?
Details:
 

Y
N
*
Are you on any medication? If yes please list which one(s) or what its is for. *You CANNOT get a piercing or tattoo if you are on antibiotics*
Details:
 

Y
N
*
Do you have any allergies? If yes please list that they are.
Details:
 

 
What is your Occupation? (School/Job)
 

*
I agree to eat something within 1 hour before your appointment?
Y
N
*
Is this your first piercing?
Y
N
*
Are you afraid of needles and/or blood?
Details:
 

Y
N
*
Have you fainted before? If yes, what from?
Details:
 

***IMPORTANT READ AND BE CERTAIN TO UNDERSTAND THE IMPLICATION OF SIGNING*** ***INITIAL EACH PROVISION ON THE LINES PROVIDED AFTER READING TO SHOW THAT YOU UNDERSTAND EACH PROVISION***
***BY CLICKING THE CHECKBOXES, or ANSWERING BESIDE EACH PROVISION AFTER READING, YOU ACKNOWLEDGE THAT YOU UNDERSTAND EACH PROVISION***

TO: TANTRIX BODY ART INC. including it’s agents, employees, officers, directors, shareholders affiliates, successors, and assigns (“Tantrix”) AND TO:_____________________(the “Artist or Piercer”); in consideration of receiving a service from the piercer or artist at Tantrix Body Art located 2A 511 1st ave N, Saskatoon, Sk, I agree to the following:
AND TO:(the "Piercer”); in consideration of receiving a service from the piercer or artist at Tantrix Body Art located 2A 511 1st ave N, Saskatoon, Sk, I agree to the following:

I Have been fully informed of the inherent risks, associated with getting a service I fully understand the risks, known and unknown can lead to injury, included but not limited to infection, scarring, difficulties in detecting melanoma and allergic reaction(s) from tattoo ink pigment, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a service, I still wish to proceed with receiving the tattoo and freely accept and expressly assume any and all risks that may arise from receiving a service.

I Understand that the Artist or Piercer is self-employed and not an employee of Tantrix and I agree not to bring any action against Tantrix and not to hold Tantrix liable for any personal injury or any claim whatsoever resulting from obtaining a service at Tantrix Body Art.

I have been given full opportunity to ask any and all questions about the application of my piercing and all questions have been answered to me total satisfaction.

The piercer will give me verbal instructions on the care of my piercing while it is healing, and I understand those instructions and agree to follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. If any issues arrise due to my own negligence, I agree that the work will be done at my own expense.
Aftercare instructions are also avalible on our website
www.tantrixbodyart.com

I am not under the influence of alcohol or drugs, and I voluntarily submitting to receive a service by the piercer without duress or coercion.

Y
N
*
I release all rights to any photographs taken of me and the tattoo or piercing and give consent in advance to their reproduction in print or electronic form.

(If you do not check this provision, please advise and remind the Artist, piercer and Tantrix NOT take any pictures of you and your completed tattoo.).
YES= PHOTO OK
NO= NO PHOTO
Y
N
*
I do not have diabetes, epilepsy, hemophilia, a heart condition nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the application or healing of the tattoo or piercing. I am not a recipient of an organ or bone marrow transplant or; if I am, I have taken the prescribed preventive regimen of anti-biotic that is required by my doctor in advance or any in advance of any invasive procedure such as tattoo or piercing. I am nor pregnant or nursing. I do not have a mental impairment that may affect my judgements in getting the tattoo or piercing. If I have diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS, or any other communicable disease, heart condition or take any medication which thins the blood I have advised my Piercer.
Details:
 

Y
N
*
I do not have a medical or skin condition(s) such as but not limited to; acne, scarring (keloid), eczema, psoriasis, freckles, moles, or sunburn in the area to be pierced that may interfere with said tattoo or piercing. If I have any type of infection or rash anywhere on my body, I will advise my Piercer.
Details:
 

I acknowledge it is not reasonably possible for the piercer to determine wether I might have an allergic reaction to the products or process used in my piercing. Any reaction products such as soap, cleanser, latex or similar products used during this process or aftercare, and I agree to accept the risk that such reaction is possible.

I realize if I have any skin treatments such as laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes in my or piercing.

I agree to reimburse the Piercer and Tantrix for any lawyer fees and costs incurred in any legal action I bring against either the Piercer and/or Tantrix and in which the Piercer and Tantrix is the prevailing party. I agree that the courts of the province of Saskatchewan shall have exclusive jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this document. The laws of the Province of Saskatchewan shall apply to the interpretation of this document.

I acknowledge that I have been given adequate opportunity to read and understand this document, that is was not presented to me last minute. I understand that I am signing a legal contract waiving certain rights to recover against the Piercer and Tantrix.

I, or Parent/ Legal guardian, acknowledge that I am over the age of SIXTEEN (or age of consent for the piercing being performed) and that I have truthfully represented to my Piercer that the obtaining of this Piercing is my choice alone. I consent to the application of the Piercing and to any actions or conduct of the representatives and staff of Tantrix reasonably necessary to perform the Piercing. 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.

I hereby WAIVE AND RELEASE to the fullest extent permitted by law each of the artist, piercer and Tantrix from all liability, damages, costs, and expenses 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, arising from or connected in any way with my tattoo or the application of my tattoo, whether caused by the negligence or fault of either the piercer or Tantrix, or otherwise.

PLEASE NOTE:
IF YOU GET LIGHT HEADED OR HAVE PASSED OUT BEFORE, or DON'T FEEL GOOD AFTER A PIERCING
We ask you to not get pierced at this time.
I agree I am telling the truth regarding this statement.

I understand if the room has to be shutdown & cleaned due to vomit, I agree to pay a $300.00 clean up fee.
The room will need to be shut down & all appointments will be cancelled afterward.

I agree to let Tantrix Body Art know, if you have been in contact with someone who is getting tested or you yourself are getting tested for Covid-19, you are required to call or message to inform us, if you have been in the studio within the past 14 days.

I agree to pay the $15 PPE fee if i am not ready or able to go through with my piercing or tattoo service.

*
I HAVE READ THIS DOCUMENT AND I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.
I HAVE READ THIS DOCUMENT AND I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

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 16 your parent/guardian will be required
Phone #:*
Email:*
Social Handle:
If you don't mind us tagging you in photos online
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.