St. Pete Piercing Consent Form

Poison Ivy Ink St. Pete

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
QUESTIONS IN FORM ARE REQUIRED BY FLORIDA LAW PLEASE FILL OUT COMPLETELY
Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of BIRTH*

MonthDayYear
Date
Age*
Race
Gender assigned at birth / or on legal documents *this info will be kept confidential*
Please upload FRONT AND BACK of valid Identification *

Cancelof
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
LOCAL URGENT CARE/ER

AFC URGENT CARE

727-821-8700

1530 Fourth St N

Saint Petersburg FL 33704

BAYFRONT HEALTH ST. PETERSBURG

727-823-1234

701 Sixth St S

Saint Petersburg FL 33701
Physician & Medical Information
Allergies and Medical Conditions*
Physician Name*
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number*
Please enter a valid phone number.
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 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 procedure.*
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 aftercare 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 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 please let your piercer know). *
I am responsible to approve the placement of the stencil *
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 Pinellas 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.*
Name *

First NameLast Name
TODAYS Date*

MonthDayYear
Date
By signing below I acknowledge I have read all above information and agree to terms, and have provided accurate information in consent form.
Signature*

Clear
Preferred Pronouns
SHOP ONLY

Please give your phone to your piercer to finish forms!
PIERCERS NAME*

First NameLast Name
PIERCERS SIGNATURE *

Clear
Type of piercing, Body Part, and Description of Jewlery *
COMPLICATION LIST*
Should be Empty:

Personal Information

Emergency Contact Information

Physician & Medical Information

SHOP ONLY