Jewelry Install/Removal or Recovery Stretch Consent Form

Jewelry Install/Removal or Recovery Stretch Consent Form

This consent form is intended for the client. If the client is under 18 years old, a parent/legal guardian will fill out the very last section. This form covers multiple piercing service types. Please note that some questions may be intended for a certain service but we are asking them for all services. If you have any questions/concerns about a question on this form, just ask our counter staff. Thank you!
Piercing service type*
Please select your piercer *
Full Name*

First NameLast Name
Name you go by if different than above
Pronouns*
Date of Birth*

YearMonthDay
Age*
Email*
example@example.com
Would you like to be added to our email newsletter?*
Phone Number*
Please enter a valid phone number.
Illness Symptoms: I confirm that I am not presenting any cold or flu-like symptoms including: dry cough, runny nose, sore throat, shortness of breath, loss of sense of taste or smell, fever - temperature: 100 degrees or above*

I confirm
COVID Preventive: Mom’s Custom Tattoo and Body Piercing has put in place preventative measures to reduce the spread of COVID-19; This includes all of our studio choosing to be fully vaccinated; however, infection from COVID-19 can happen anywhere and no business can guarantee or completely prevent someone from becoming infected. Further, being in any business could increase your risk of contracting COVID-19*

I acknowledge
Medications: Are you currently taking any medications that would interfere with the procedure or the healing of the piercing such as: Blood Thinners, Glucocorticoid Steroids, or Chemotherapeutic Drugs?*
If yes, please explain:
Medical Conditions: Do you have any medical conditions that would interfere with the procedure or the healing of the piercing such as in diabetes, epilepsy, hemophilia, heart condition, or a skin condition?*
If yes, please explain:
Pregnant or Nursing: Are you currently pregnant or nursing?*
Organ or Bone Marrow Transplant: Are you the recipient of an organ or bone marrow transplant that has not taken the prescribed preventive regimen of antibiotics that is required by your doctor in advance of any invasive procedure such as piercing?*
Eaten: Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels*
Duress: I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress*

I affirm
Aftercare: I understand that upon completing this consent form I will receive a copy of the aftercare to the email I provided. If I do not receive the aftercare information, it is my responsibility to contact Mom’s Custom Tattoo and Body Piercing to request a copy of the aftercare. I acknowledge that it is my responsibility to follow these aftercare instructions and that it is possible that the piercing can become infected, particularly if I do not follow the instructions.*

I acknowledge
Permanent change: I acknowledge that the piercing will result in a permanent change to my appearance and that my skin may not be restored to its pre-piercing condition even after its removal*

I acknowledge
Risks: I acknowledge that I have been fully informed of the risks associated with getting a piercing. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring and keloiding and allergic reactions. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept all risks that may arise from piercing*

I acknowledge
Release: TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artists and Mom's Custom Tattoo & Body Piercing from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise*

I agree
Attorney Fees: I agree to reimburse each of the Artist and Mom's Custom Tattoo & Body Piercing for any attorneys, fees, and costs incurred in any legal action I bring against either the Artist or Mom's Custom Tattoo & Body Piercing and in which either the Artist or Mom's Custom Tattoo & Body Piercing is the prevailing party. I agree that the courts of Spokane in Washington, USA shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement*

I agree
Photography: I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form. (If you do not initial this provision, please advise and remind your Artist and NOT to take any pictures of you and your completed piercing!)*
Follow Up: Do you consent to follow up contact to check on your piercings healing progress? Default contact mode is email, inform your piercer if you would prefer a different method*
Deposits: Deposits will apply to my appointment for my service. They are nonreturnable and nonrefundable. During payment, the deposit will be applied first and whatever payment method you prefer can be used after that (this includes cash, card, or gift card).*

I understand
Pricing: I know the cost of my procedure/jewelry and have enough money to cover the full amount including tax. I will pay after the procedure, and understand that once the jewelry is in me, it's mine. I also understand that there are no refunds or returns on my piercing and jewelry.*

I agree
Jewelry Installs/Stretching a Piercing: I understand that if I've had my jewelry out for longer than a few hours or thinner jewelry than the new jewelry selected, that my piercing channel will have shrunk and installing new jewelry will stretch my piercing open again. I understand that my piercing may be sore for 2-3 weeks from stretching the piercing to the jewelry's gauge size. Healing times will vary depending on stretch. My piercer will give me aftercare timelines for my stretch.*

I understand
Recovery Stretch: Recovery Stretching is dependent on the current healing status of the piercing channel. I understand that if a recovery stretch attempt is made but my piercing channel is full healed, I am still subject to pay the recovery stretch fee to cover the handling and materials used in the process.*

I understand
This Document: I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract*

I acknowledge
Questions: I acknowledge that both the Artist and Mom's Custom Tattoo & Body Piercing have given me the full opportunity to ask any and all questions about the piercing procedure and the they have been answered to my total satisfaction*

I acknowledge
I understand I may request my service provider to wear a mask for the duration of my appointment.*

I understand
I understand my service provider may request that I wear a mask during my appointment.*

I understand
If I have a scheduled appointment for a future date and decided to come in as a walk in today to receive that service earlier than the scheduled appointment time, I acknowledge that it is my responsibility to relay that information to the counter staff at check out to be sure my deposit is applied to todays walk in service and to ask for my future appointment that I no longer need to be cancelled.*

I understand
Signature*

Clear
Please take a photo of your valid identification card*
Military ID
We can not take a photo of Military ID, please type in your military ID number below.
If the client is under 18 years of age, please have a parent/guardian fill out the section below
Please take a photo of your parent/guardian's valid identification card
Military ID
We can not take a photo of Military ID, please type in your military ID number below.
Parent/Guardian Name

First NameLast Name
Relation to client

Birth ParentAdoptive ParentLegal GuardianParent By MarriageOther
Parent/Guardian Date of Birth

MonthDayYear
Parent/Guardian Phone Number if different than at the top of the form
Please enter a valid phone number.
Parent/Guardian Email if different than at the top of the form
example@example.com
Parent/Guardian Signature

Clear
Thank You!

We recognize that you have a choice to make when it comes to your body modification needs and we appreciate that you have chosen us for your piercing today. 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.
Once this page re-directs, please don't fill out any other form unless explicitly told to do so by your service provider or our counter staff. Any form filled out without instruction to do so will be voided.
Should be Empty:

Jewelry Install/Removal or Recovery Stretch Consent Form

If the client is under 18 years of age, please have a parent/guardian fill out the section below

Thank You!

Once this page re-directs, please don't fill out any other form unless explicitly told to do so by your service provider or our counter staff. Any form filled out without instruction to do so will be voided.