Piercing Release Form (Adult)

Piercing Release Form

Tattoo Republic LLC Adult Piercing Consent and Liability Release Form
Take a clear picture of the front of your ID*
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Drivers License #*
Date Of Birth*

MonthDayYear
Date
Piercing Type
example: Lobes, Nose, Belly Button, etc

Covid-19 Health Screening Questionnaire*

I do not have symptoms of COVID-19 and accept to follow the rules of the shop during my appointment.I have not had contact with anyone who may have symptoms of COVID-19 or get infected by the virus within 14 days.

If any provision, section, subsection, clause or phrase of this release is found to be
unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

I hereby declare that I am of legal age (and have provided valid proof of age and
identification) and am competent to sign this Agreement. I declare that I release Tattoo Republic LLC, its employees, agents, artists or any representatives from all liabilities or damages.
I First Name Last Name on Date HAVE READ THE AGREEMENT WITH TATTOO REPUBLIC LLC, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.
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