OUTER LIMITS PIERCING CONSENT FORM
Name
*
First Name
Last Name
Preferred name (if different than legal name)
Pronouns
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date Of Birth
*
-
Month
-
Day
Year
Date
How Did You Hear About Us?
*
Age:
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Piercer / Practitioner
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Luc Scott
Gregg M.
Hanna Siso
Piercing Type:
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Have you been pierced by us before?
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Yes
No
I have eaten in the last 3 hours:
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yes
no
Please add photo of your valid ID. Must be government issued, Photo ID. Driver License, State ID, or Passport.
*
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Please Read And Initial
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions I might have about obtaining a piercing from Outer Limits Tattoo & Body Piercing, (hereinafter referred to as "Outer Limits") and that all of my questions have been answered to my full and total satisfaction. I acknowledge that I have been advised of the facts and matters set forth below and by my initials I agree to the following:
I am the person on the legal ID presented as proof that I am at least 18 years of age.
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INITIALS
I acknowledge that I am not under the influence of drugs and/or alcohol and I am voluntarily submitting to be pierced without duress or coercion. I consent to the body piercing and to any actions or conducts reasonably necessary to perform the body piercing procedure.
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INITIALS
I do not have any physical, mental, or medical conditions which may affect my well being as a result of my decision to receive a body piercing at this time.
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INITIALS
I understand that the resident County Health Department does not allow piercing on skin surfaces with sunburn, rash, pimples, infections, open lesions, moles, or skin manifests any evidence of unhealthy conditions.
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INITIALS
I acknowledge that it is not reasonably possible for the artist or any representative of "Outer Limits" to determine whether I might have an allergic reaction to the metals, solutions or processes used for my body piercing, and I agree to accept the risk that such a reaction is possible.
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INITIALS
I acknowledge that an infection is always possible, particularly in the event that I do not take proper care of my body piercing. I also agree to follow all instructions concerning the care of my piercing while it is healing, and will receive written instructions on the aftercare of my piercing.
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INITIALS
l understand that there is potential for adverse healing (such as keloid formation or hypertrophic scarring) that may only be removed by surgical procedure, which may leave permanent scarring and/or disfigurement.
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INITIALS
I hereby give my artist and/or Outer Limits permission to copyright and/or use and/or publish photographic portraits of pictures of me or in which I may be included in in part of reproductions thereof made through any media for art, advertising, or any other lawful purposes whatsoever. I waive any right I may have to inspect and/or the finished product or the use to which it may be applied.
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INITIALS
I agree to release and forever discharge and hold harmless Outer Limits or any representative or subcontractor from any and all claims, damages, or legal actions arising connected in any way with my tattoo, or the procedure and/or conduct used in the application of my tattoo. However, if I feel I have a dispute that cannot be resolved by directly with Outer Limits or its representatives, then I agree to submit to binding arbitration by a retired judge in the resident county.
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INITIALS
To my knowledge, I have not been infected with Covid-19 or exposed to any other persons infected with Covid-19.
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INITIALS
I understand that all jewelry and piercing or aftercare related items or accessories are FINAL SALE and that no refunds or exchanges will be offered.
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INITIALS
Please check any of the following conditions that apply:
Check
Covid-19 / Coronavirus (or exposure)
Iodine Allergy
Diabetes
HIV / AIDS
Heart Condition
Faint or Dizzy
Epilepsy
Hemophilia
Eczema / Psoriasis
Infections
T.B.
Scarring / Keloiding
Herpes
Asthma
Hepatitis
Pregnant / Nursing
Cardiovascular Disease
Blood Thinners
Please list any allergies, diseases, conditions, medications (including antibiotics prior to dental or surgical procedures) or any known illnesses below. If none, write "none".
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Signature of Client:
*
Date:
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/
Month
/
Day
Year
Date
Submit
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