Tampa Piercing Consent Form

Poison Ivy Ink LLC

Tampa Piercing Consent Form
If you are a minor please request paper form
How did you hear about us?
Is this your first time receiving a service from us?

YesNo, returning client
Personal Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of BIRTH*

MonthDayYear
Date
Age*
Race
Please upload a photo of the FRONT AND BACK of your valid ID*

Cancelof
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Physician & Medical Information
Allergies & Medical Conditions *
Physician Name*
Physician Phone Number*
Please enter a valid phone number.
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
LOCAL URGENT CARE/ER

Concerta Urgent Care

813-980-3151

10320 N 56th St Suite 110

Temple Terrace FL 33617

Advent Health Tampa ER

813-971-6000

3100 E Fletcher Ave

Tampa FL 33613
I have been fully informed of the inherent risks associated with getting a piercing. Therefore, I fully understand these risks, known and unknown, can lead to injury, scarring, and/or infection. I also understand the risk of allergic reaction to gloves, soap, or jewelry. While being aware of these risks I still would like to proceed with the piercing.*
I waive and release to the fullest extent permitted by law any person of Poison Ivy Ink LLC from all liability whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors, or assigns, at have for personal injury or otherwise, including any direct or/consequential damages, which result or arise from the procedure and application of my piercing, whether caused by the negligence or fault of either the artist or otherwise. *
I have been given full opportunity to ask questions about piercing procedure, and my questions have been answered to full satisfaction. *
I have been given after care instructions. I acknowledge there is a risk of infection especially I do not follow the aftercare instructions. *
I am not under the influence of drugs or alcohol. I am voluntarily submitting to be pierced. *
I do not suffer from epilepsy, diabetes, hemophilia, heart condition(s) and I do not take any blood thinning medicines. I don’t have any skin or other conditions that would interfere with the piercing. I am not a recipient of organ or bone marrow transplant, and if I am I have taken the prescribed preventive regimen of antibiotics that is required by my doctor. I am not pregnant or nursing. I do not have a mental impairing that may affect my judgment in getting a piercing. *
I understand this is a permanent change to my appearance.*
I understand I am responsible to approve the placement of the stencil.*
I release the right to take any photographs of me and the piercing and give consent in advance to their reproduction in print or electronic form. (If you do not agree to this please let your piercer know). *
I understand payment is due at the end of the piercing and there is a NO REFUND policy. *
I agree to reimburse Poison Ivy Ink LLC for any attorney fees and costs incurred in any legal action brought against the Poison Ivy Ink LLC and in which either the artist or Poison Ivy Ink LLC is the prevailing party. I agree that the courts located in the County of Hillsborough within the state of Florida shall have jurisdiction and venue over me send shall have exclusive jurisdiction for the purpose of ligating any dispute arising out of or related to this agreement. *
I acknowledge I have been given plenty of time to read over and understand this agreement.*
I herby declare I am of legal age and have provided valid period of age and identification.*
TODAYS Date*

MonthDayYear
Date
Name*

First NameLast Name
I have read the agreement, I understand it, and I agree to be bound by it. Signature:
Signature*

Clear
Preferred Pronouns
SHOP USE ONLY

Please show this portion to Shop Manager or Artist.
Piercer Name*

First NameLast Name
Piercer Signature*

Clear
Type of Piercing; Body Part; and Description of Jewelry*
Complication List*
Should be Empty:

Personal Information

Emergency Contact Information

Physician & Medical Information

SHOP USE ONLY