Piercing Consent Form

Date of Appointment

Date

Please select a Piercer

Piercing Placement

I acknowledge that I am at least 18 years of age, and can provide valid identification*

Yes, I am 18 years or older

I acknowledge that I am not pregnant or nursing.*

Yes

I affirm am not under the influence of any illicit drugs, or alcohol.*

Yes

I will bring to the attention of my piercer, any medications I have consumed within the last 24 hours.*

Yes

I am not aware of any major health problems which may complicate my procedure and/or I have consulted with amedical professional regarding any health concerns.*

Correct, I am not aware of major health problems

Do you have/have you ever been exposed to any of the following. Please check any that apply below.

Blood borne pathogens including, but not limited to HIV/AIDSSkin diseases or skin lesions around the piercing areaHistory of epilepsy, seizures, fainting, or narcolepsyUse of medications such as anticoagulants, which thin the blood and/or interfere with blood clottingHepatitis B or C (HBV or HCV)History of Hemophilia (bleeding)Diabetes

If you checked any of the above boxes, please review and initial here to indicate this is correct.

While exposure to, or having tested positive for any of the above does not prohibit us from providing you services, many of the illnesses could lead to increased risk of infection, trouble with blood clotting, or other potential health risks. By initialing above, you are releasing the artist, Lore Tattoo LLC, and any of its affiliates from liability regarding complications related to these risks and have consulted with a medical professional regarding any risks associated with receiving piercing, or other body art.

I do not have any allergies or sensitivities to materials such as metals, latex, soap, rubbing alcohol, disinfectants, or other skin sensitivities*

No, I do not have any allergiesYes, I have allergies I will list below

Please list any allergies or sensitivities we may need to know about.

I acknowledge that I have eaten within the past 4 hours or will eat within 4 hours of my scheduled appointment.*

Yes

If you are receiving an oral piercing that may cause damage to teeth/gums, you must initial that you are aware and release Lore Tattoo LLC from any liability, and still give consent.

Initial Above

I will make it known to my piercer if I feel; overly hot/cold, nauseous, dizzy, lightheaded, numbness, tingling or any other symptoms during the procedure.*

Yes

To the best of my knowledge I have not been in contact with anyone infected with COVID-19. I have not experienced or been exposed to someone with symptoms, fever, cough, shortness of breath, chills, body aches, or sore throat within the last 14 days.*

Yes

I have been fully informed of the inherent risks associated with getting a piercing. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, and allergic reactions to piercing metals, latex gloves, or piercing rejections. Having been informed of the potential risks, I still wish to proceed with the piercing procedure and I freely accept and expressly assume any and all risks.*

Yes

PHOTOGRAPHY - I release all rights to any photographs taken of me and the piercing I get and give permission/consent in advance to their production in print and electronic form for artists/studio use of portfolios and marketing materials or other uses deemed necessary.

YesNo

LEGAL ACTION - I agree to reimburse each of the piercers or Lore Tattoo LLC for any attorney fees and costs incurred in any legal action I bring against either the piercer or Lore Tattoo LLC in which either the piercer or Lore Tattoo LLC is the prevailing party. I agree that the courts of Utah, USA shall have the jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating and disputes arising out of or related to this agreement.*

I agree

I understand that a piercing is a permanent change to my appearance and that no representation has been made to me as to the ability to later restore the skin involved to its pre-piercing condition. My skin may not be restored to its pre-piercing condition even after its removal.*

I understand

I affirm that I will follow aftercare instructions for my piercing while it heals. I acknowledge infection is always possible as a result of obtaining a piercing, particularly if I do not follow aftercare instructions.*

I agree

I understand that piercings can take anywhere from 6-12 months to heal.*

I understand

I understand that my piercing will be performed using a sterilized, single-use needle, sterilized implements and jewelry.*

I understand

I understand that if jewelry installed by Lore Tattoo falls out within (1) week, we will replace this piece of jewelry for free. Any longer than (1) week, it becomes my responsibility.*

I understand

I acknowledge that I have read and understand this disclosure form, and any/all information is correct to the best of my knowledge.*

Yes

Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

By signing below you are releasing Lore Tattoo LLC, and any/all affiliates of the company including your artist, from any/all claims, damages and/or legal actions, arising from, or in connection with the procedure about to be performed. Also, by signing you are giving your full permission to Lore Tattoo LLC and its artists to use any imagery or photography of the procedure without any restitution.

I hereby give my informed and specific consent to Lore Tattoo LLC and its artists to perform the procedure. I hereby declare that I am of legal age and have provided proof of age and am competent to sign this agreement.

Please upload a copy of your unexpired, valid ID. Front and Back. Clear and Legible.

I.D. Upload (Front)*

Multiple files accepted

I.D. Upload (Back)*

Multiple files accepted

Signature*

Lore Piercing Consent Form