Client Information
Full Name
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First Name
Last Name
Preferred Name
First Name
Last Name
Pronouns
Age
*
Date of Birth
*
-
Month
-
Day
Year
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.
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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.
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Yes
No
I am at least 18 years old.
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Yes
No
Do you have any medical conditions that we need to be aware of?
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Yes
No
Are you pregnant/breastfeeding?
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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, we have snacks.
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Yes
No
Are you prone to fainting?
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Yes
No
I agree to speak softly and silence my cell phone in order to help keep a calm, spa like environment.
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Yes
No
Are you currently sick? In the last 14 days, have you been sick or been in contact with anyone that is sick.
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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.
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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.
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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?
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Yes
No
Are you allergic to any of the following?
Adhesives
Lavender Oil
Tea tree Oil
Witch Hazel
Acknowledgment and Waiver
*
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.
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I understand there are no refunds.
*
I consent to Authorization for Picture of my Jewelry Change to be used on Social Media, Website etc
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
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-
Month
-
Day
Year
Date
Client Signature
*
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