Piercing Consent 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 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. *

Yes No

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. *

Yes No

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. *

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 a heart condition? *

Yes No

Do you have Diabetes? *

Yes No

Do you have epilepsy? *

Yes No

Do you suffer from Hemophilia? *

Yes No

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

Yes No

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

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, we have snacks). *

Yes No

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

Yes No

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

Yes No

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

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 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. *

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 pierced. *

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

Are you allergic to any of the following? *

Adhesives Lavender Oil Tea tree Oil Petroleum Stainless Steel Iodine NONE

Please list any medications you take

*

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

*

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 *

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)

Client Information

Acknowledgment and Waiver