Jewelry Insertion Waiver

1

Legal Name* This field is required.

First Name

Last Name

2

Preferred NameIf different

First Name

Last Name

3

Pronouns

4

Birthdate* This field is required.

Date

5

Phone Number* This field is required.

Please enter a valid phone number.

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:* This field is required.I am the person on the legal ID presented as proof that I am at least 18 years of age

Clear

7

* This field is required.I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Clear

8

* This field is required.I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.

Clear

9

* This field is required. 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.

Clear

10

* This field is required.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.

Clear

11

* This field is required.I understand there is a possibility of an allergic reaction to any jewelry inserted into the fresh body piercing.

Clear

12

* This field is required.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.

Clear

13

Was the jewelry you would like inserted purchased OUTSIDE of this facility?* This field is required.

YESNO

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.

Clear

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.

Clear

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.

Clear

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.* This field is required.

Clear

18

Today’s Date

Date

19

Practitioner* This field is required.