Jewelry Change Out Form

Full Name *

First Name Last Name

Preferred Name

First Name Last Name Pronouns

Age *

Date of Birth *

Date

Phone Number *

Area Code Phone Number

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

I hereby give consent to Zen Ink, LLC to remove my body piercing or change my jewelry, and in consideration of doing so, I hereby release and forever discharge and hold harmless Zen Ink, LLC, the Piercer and all affiliates, Owners, Managers and Independent Contractors from any and all claims, damages or legal actions arising from or connected in any way with my procedure and conduct used in my performing my procedure, to the fullest extent allowed by the law. *

Yes No

I agree that these waivers also pertain to and are designed to protect any and all establishments of Zen Ink and their Independent Contractors. *

Yes No

I am at least 18 years old. *

Yes No

Do you have any medical conditions that we need to be aware of? *

Yes No

Are you pregnant/breastfeeding? *

Yes No

Have you eaten in the last 5 hours? It's a good idea to eat before hand to increase your blood sugar levels. (If you have not, there is a higher risk for passing out/getting sick, so please ASK us for a snack before we start). *

Yes No

Are you prone to fainting? *

Yes No

I agree to speak softly and silence my cell phone in order to help keep a calm, spa like environment. *

Yes No

Are you currently sick? In the last 14 days, have you been sick or been in contact with anyone that is sick. *

Yes No

I understand the Zen Ink has put additional protective measures in place in order to reduce the risk of contamination, virus, or pathogen but it is impossible to completely eliminate that risk. *

Yes No

I agree to release and forever hold harmless Zen Ink and its agents and representatives for any and all claims, damages, or legal actions in the event I contract COVID-19 or any other illness after choosing to get jewelry changed. *

Yes No

Have you experienced any symptoms (fever, cough, shortness of breath, chills, body aches, sore throat), had exposure to someone exhibiting COVID-19 symptoms or confirmed illness within the last 14 days, or have you traveled? *

Yes No

I consent to Authorization for Picture of my Jewelry Change to be used on Social Media, Website etc *

Yes No

I agree that an apprentice can do my jewelry change (if applicable). I acknowledge and I am fully aware that my piercer is an apprentice and still learning. I understand that apprenticeships are a form of on-the-job training where the art of the piercing can be taught, along with techniques for avoiding blood-borne pathogens, handling needles, and studio etiquette. I understand that apprentices are still getting valuable hands-on experience and learning the craft of piercing. I am aware that this piercing apprentice does have valid up to date Blood Bourne Pathogen (BBP) training certificate. I understand the risks involved and consent to have a jewelry change by this piercing apprentice. *

Yes No Not Applicable

Are you allergic to any of the following? *

Adhesives Lavender Oil Tea tree Oil Witch Hazel Latex NONE

*

I have read this 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.

*

I understand there are no refunds.

*

I confirm that the information I provided in this document is accurate and true.

Signed Date *

Date

Client Signature *

Clear

Client Information

Acknowledgment and Waiver