Body Piercing Release Form

Let us do this part
Today's Date:
Sat Jul 11 2020 12:26
Artist:*
Body Piercing Location:*
Body Piercing Price:*
Please read & answer
ID*
I confirm I have a suitable Government issued Photo ID such as a drivers license or passport (not a student ID) present and will take a photo of it (or ask staff to assist) at the end of this form.
Price*
I confirm I have checked the price (listed above) and have either cash or a suitable debit/credit card. AMEX cards are not accepted.
Eaten*
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.
Booze*
Have you had any alcoholic beverages in the last eight (8) hours? Let us know if so and how much.
Blood Thinners*
Have you taken aspirin, ibuprofen or blood thinners in the last twenty four (24) hours? Let us know if so and what
Bleeding*
Are you prone to heavy bleeding? It's okay if you are - we just need to know.
Fainting*
Are you prone to fainting? It's okay if you are - we just need to know.
Pregnant/nursing*
Are you currently pregnant or breastfeeding?
Blood Pressure*
Do you have high blood pressure? It's okay if you do - we just need to know.
Allergies*
Do you have a latex allergy or any other allergies? Please let us know if so
Details:
 

Medical conditions*
Do you have any other conditions which might affect the healing of this piercing? Please let us know if so
Details:
 

Release*
I hereby give consent to a piercing insertion/assessment/removal or stretch and in consideration of doing so, I hereby release the studio, and its employees and agents from all manner of liabilities, claims, actions and demands in law or in equity, which I or my heirs might now or hereafter by reason of complying with my request to have jewellery inserted/removed or to have my piercing assessed or stretched.
Medical*
I fully understand that any employee or agent of this studio when performing a piercing insertion/removal/assessment or stretch does not act in the capacity as a medical professional. The suggestions made by any employee or agent of this studio are just suggestions. They are not to be construed as, or substituted for advice from a medical professional.
Questions*
I acknowledge both the Artist and the Piercing Studio have given me the full opportunity to ask any and all questions about the piercing procedure and the they have been answered to my total satisfaction.
Aftercare*
I understand my aftercare will both be explained to me verbally and a copy will be emailed to me. I have had the opportunity to ask any questions in regards to aftercare and they were explained to my satisfaction. I understand that a piercing may take several months to heal properly and I am responsible for caring for the piercing appropriately during this time.
Risks*
I willingly submit to these procedures with a full understanding of possible complications such as, but not limited to, infection, allergic reaction or rejection of this piercing. 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.
Permanent Change*
I understand that by having this piercing performed that I am making a permanent
change to my body and no claims have been made regarding the ability to undo the changes made.
This Document*
I have read this Body Piercing Consent & Release Form and confirm that all the information I have given is correct. I understand that this is a release form and I agree to be legally bound by it.
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. (You do not have to agree to this box if you don't wish to have your photo taken)
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.
Name:*
Address:
Date of birth:*
If you are under 16 your parent/guardian
Phone #:
Email:*
Signature:*


Photo ID(s)*
Please take photo(s) of your government issued photo IDs and related paperwork.
Enter passcode to submit: