Piercing Consent Form

Waiver, Release, and Consent to Piercing

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

PLEASE INITIAL EACH PROVISION ON THE LINES PROVIDED IN THE LEFT COLUMN

AFTER READING TO SHOW THAT YOU UNDERSTAND EACH PROVISION.

Whereas, the undersigned Client desires to receive body piercing at (Name of Studio) (the Studio) located at (street address, city, state, zip code), from (Name of Artist), hereinafter called Artist;

Therefore, for and in consideration of receiving a body piercing from Artist, at (Name of Studio) (the Studio), I, the undersigned, agree to the following:

_____ 1. I, (clearly PRINT your name) have been fully informed of the inherent risks, associated with getting a piercing. I fully understand that these risks, known and unknown can lead to injury, including but not limited to infection, scarring and keloiding, allergic reactions to jewelry, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept and expressly assume any and all risks that may arise from piercing.

_____ 2. I hereby WAIVE AND RELEASE to the fullest extent permitted by law (Name of Artist), the Studio, and the Staff of the Studio 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 from the piercing, whether caused by the negligence or fault of the Artist, Studio, or a member of the Staff of Studio.

_____ 3. Both the Artist and Studio have given me the full opportunity to ask any and all questions about the piercing procedure and have answered these questions to my total satisfaction.

_____ 4. I affirm that both the Artist and Studio have given me instructions on the care of my piercing while it’s healing, and I understand them and will 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.

_____ 5. I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress. I further affirm that I do not have diabetes, epilepsy, hemophilia, nor do I have a heart condition nor do I take blood thinning medication. I do not have a medical or skin condition that may interfere with the procedure or healing of the piercing. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of antibiotics that are required by my doctor in advance of any invasive procedure such as piercing. I am not pregnant or nursing.

_____ 6. 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.

_____ 7. I release all rights to any photographs taken of me before, during and after the piercing and give consent in advance to their reproduction in print or electronic form for use in advertisements and for educational purposes. (If you do not initial this provision, please advise and remind your Artist and/or the Piercing Studio NOT to take any pictures of you and your completed piercing).

_____ 8. I acknowledge that I have read and that I understand this document, and that I am signing a legal contract waiving rights of recovery against the Artist and/or the Studio and its Staff.

_____ 9. I agree to indemnify and save the Artist, Studio and Staff harmless from and against all costs and losses to my person or property in connection with the piercing, including, but not limited to, any loss, liability, attorneys’ fees, damage, or costs that they (or any of them) may incur arising out of or related to said piercing.

_____ 10. The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision.

_____ 11. Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect.

_____ 12. Parent or Guardian must sign if Client is under 18 years of age.

Witness my signature this the day of , 20 .

I, as parent or guardian of the above named Participant agree individually and on behalf of my child or ward, to the terms of the above Waiver, Release, and Consent.

WITNESS my signature on this the day of , 20 .