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17
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1
Legal Name
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First Name
Last Name
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2
Preferred Name
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First Name
Last Name
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3
Pronouns
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4
Birthdate
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Date
Year
Month
Day
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5
Phone Number
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Please enter a valid phone number.
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6
In consideration of receiving A Jewelry Change Service from the practitioner at VELVET ORANGE BODYCRAFT (together with its employees, it’s apprentices, and agents, the “Body Art Business”) I confirm the following by initialing each applicable item:
*
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I am the person on the legal ID presented as proof that I am at least 18 years of age
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7
*
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I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).
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8
*
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I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
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9
*
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I understand that physical distancing will not be possible during this procedure and that by undergoing this procedure I may increase my risk of contracting pathogens including but not limited to COVID-19.
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10
*
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I understand that all piercings pose risks including but not limited to; infection, migration, stretching, tearing and/or rejection. Changing the jewelry within a piercing can exacerbate this risk.
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11
*
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I understand there is a possibility of an allergic reaction to any jewelry inserted into the fresh body piercing.
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12
*
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I understand that changing my jewelry before my piercing is healed is likely to result in migration, rejection, scarring, stretching and/or irritation. I confirm that my piercing is healed according to the guidelines set forth by my piercer.
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13
Was the jewelry you would like inserted purchased OUTSIDE of this facility?
*
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YES
NO
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14
I understand that I am responsible for knowing the gauge, material and functionality of the body jewelry that I have purchased for insertion. Any damage to my jewelry or piercing resulting from this insertion is solely my responsibility.
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15
I understand that the Body Art facility makes no warranty whatsoever as to the quality, cleanliness or fitness for use of any and all jewelry purchased outside of this facility.
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16
I understand that jewelry purchased from outside of a Licensed Body Art Facility is not legally required to be non toxic or safe for insertion into the human body. I assume all risks stemming from its use and have been advised of its danger.
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17
I have been fully informed of the risks of body art including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with a body art procedure, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art.
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18
Today’s Date
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Date
Year
Month
Day
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19
Practitioner
*
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Shar
Delia
Shar
Delia
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20
Identification
ID/DL
Birth Certificate
Passport
Tribal ID
Other
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