Body Piercing/Modification Consent Form for Clients Under 18 years old.
Form to be completed by Client under the supervision of their Parent or Legal Guardian
Client Information
Name
*
First Name
Last Name
Age
*
Birth Date
*
-
Day
-
Month
Year
Date
Phone Number
*
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Acknowledgment and Waiver
*
I am not under the influence of any alcohol, intoxicants or narcotics.
*
I acknowledge that aftercare instructions will be provided and I agree to follow these instructions and be held solely responsible for the aftercare of my piercing.
*
I fully understand that any employee or agent of this studio when performing a piercing insertion/removal/assessment or stretch does not act in the capacity as a medical professional. The suggestions made by any employee or agent of this studio are just suggestions. They are not to be construed as, or substituted for advice from a medical professional.
*
I understand that jewellery will be inserted or removed using appropriate techniques and instruments. I willingly submit to these procedures with a full understanding of possible complications such as, but not limited to, infection, allergic reaction or rejection of this piercing. I understand that a piercing may take several weeks to heal properly.
*
I confirm that I do not currently suffer any medical conditions either physical or psychological that will affect your health, as a direct or indirect result of my decision to have a piercing or body modification.
*
I acknowledge that the Tattoo Studio does not offer refunds.
*
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used during the piercing or body modification procedure including jewellery.
*
I indemnify and hold harmless South West Tattoo Studio against any claims, expenses, damages, and liabilities.
(If stretching) I understand that my piercing will be stretched only one size at a time (no more than one gauge or a few millimetres at a time) using no flare or single flare jewellery only (double flare not allowed).
I allow my piercings to be photographed and be used for Studio's Portfolio and Social Media accounts.
Answering "Yes" to any of the questions does not necessarily preclude the client from receieving a body piercing.
Have you eaten in the last 4 hours?
*
Yes
No
Have you taken aspirin, ibuprofen or blood thinners in the last twenty four (24) hours?
*
Yes
No
Are you prone to heavy bleeding?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Are you prone to fainting?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have a latex allergy?
*
Yes
No
Please tell about your medical history (e.g. Allergies, Skin Conditions, Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
*
I confirm that the information I provided in this document is accurate and true.
Please read and be certain you understand the implications of signing
South West Tattoo Studio Piercing/Modification disclaimer statement:
All consumable instruments used in the process of tattooing are single use items only. Any non-consumable equipment used is sterilised in an approved autoclave before re-use in accordance with State and Health Regulations. I acknowledge that the sterilisation method used was explained to my full satisfaction. I had the opportunity to ask questions regarding this procedure. All questions were answered to my satisfaction. All equipment during the procedure was opened in front of me. I witnessed the disposal of the piercing needle(s) into regulated sharps containers. Both written and verbal Body Piercing Aftercare Instructions were provided to me. I have read this Body Piercing Consent & 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 AGREE TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist's and the Tattoo Studio from all liability. All claims or causes of action that I may have for personal injury or otherwise, including any direct and/or consequential damages, have not been caused by the negligence or fault of any of the Artists or the Tattoo Studio.
I have read and understood the information that has been provided and I am consenting to be pierced of my own free will. I do hereby release Neale Cheetham, the Artists and any other person acting on behalf of South West Tattoo from any responsibility or liability.
Signed Date
*
-
Day
-
Month
Year
Date
Client Signature
*
Name of Parent or Legal Guardian
*
First Name
Last Name
Parent or Legal Guardian's Signature
*
Submit
Should be Empty: