Piercing Consent Form

Client Information
Piercer Name
What are you getting pierced today?
Full Name*

First NameLast Name
Preferred Name

First NameLast NamePronouns
Age*
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby give consent to Zen Ink, LLC to perform a body piercing, and in consideration of doing so, I hereby release and forever discharge and hold harmless Zen Ink, LLC, the Piercer/Artists 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 piercing procedure and conduct used in my performing my piercing, to the fullest extent allowed by the law.*

YesNo
I fully understand that any Independent Contractors of Zen Ink, LLC when performing a body piercing, do not act in the capacity as a medical professional. The suggestions made by any Independent Contractors or agent of Zen Ink, LLC are just suggestions. They are not to be construed as, or substituted for advice from a medical professional. I understand that the body piercing will be performed using appropriate techniques and instruments. I also understand that infections can occur due to lack of proper hygiene and metal sensitivities.To ensure proper healing of my body piercing, I agree to follow the written and verbal aftercare instructions that will be provided, until healing is complete. I understand that a body piercing may take several months to heal properly.*

YesNo
I understand that I am making a modification to my body, and no claims about the possibility of reversing these changes have been made or implied by Zen Ink, LLC or any of its Independent Contractors or agents.*

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

YesNo
I am at least 18 years old.*

YesNo
Do you have a heart condition?*

YesNo
Do you have Diabetes?*

YesNo
Do you have Epilepsy?*

YesNo
Do you suffer from Hemophilia?*

YesNo
Do you have Hepatitis/HIV or any other communicable disease?*

YesNo
Do you have sunburn, discoloration, lumps around the piercing area?*

YesNo
Are you pregnant/breastfeeding?*

YesNo
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).*

YesNo
Do you suffer from any condition that makes this procedure dangerous?*

YesNo
Have you consumed drugs/alcohol in the last 8 hours? if so, what and how many?*

YesNo
Have you recently taken: blood thinners, antibiotics, prednisone, accutane?*

YesNo
Are you prone to fainting?*

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

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

YesNo
I understand that getting pierced does temporarily stress the body and the immune system, which could make me more susceptible to illness and infection. I accept this risk.*

YesNo
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.*

YesNo
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 pierced.*

YesNo
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?*

YesNo
If being pierced by an apprentice: 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 Borne Pathogen (BBP) training certificate. I understand the risks involved and consent to have a piercing by this piercing apprentice.*

YesNoNot Applicable
I consent to Authorization for Picture of my Piercing to be used on Social Media, Website etc*

YesNo
Are you allergic to any of the following?*

LatexAdhesivesLavender, Tea Tree OilPetroleumIodineNONE
Please list any medications you take
How did you hear about us?*

Repeat ClientReferralInstagramRadioDig Local Website/AppGo Local Discount CardDig LocalSilveradosBest of WNC
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.
*

I understand there are no refunds.
*

I understand that I need to take care of the piercing by following the instructions given to me by the Tattoo Shop.
*

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

MonthDayYear
Date
Client Signature*

Clear
Please take a picture of your Drivers License or Passport*
For Minors:

Parent must be present at time of Piercing. We will also need proof of parenthood at time of piercing. This will be something that says you are the parent/legal guardian. Examples are: Child and parent IDs with matching last names and addresses, Birth Certificate and Parent ID, Court Issued paperwork and ID.
Parent Signature

Clear
Photo of any additional documentation (for minors only)
Should be Empty:

Client Information

Acknowledgment and Waiver