Piercing Consent Form

Name

First NameLast Name

Birthdate

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Driver’s License/State ID/Identification Card

How did you hear about us? (Instagram, Google, TikTok, referral)

The nature and method of the proposed body piercing prod ruder has been explained to me as having the usual risks inherent in the procedure and the possibility of complications during and following its performance. I understand that there may be a certain amount of discomfort or pain associated with the procedure and that other possible adverse side effects may include: minor and temporary bleeding, bruising, redness or other discoloration and/or swelling. I fully understand the risks of body piercings including but not limited to infection and other medical complications, allergic reactions to metal jewelry, and antibiotics. Secondary infection in the area of the procedure is rare if properly cared for, but may occasionally occur. Having been informed of the potential risks associated with the receving a body pericing, I still wish to proceed with the procedure. I assume any and all risks that may arise from the body piercing. By signing below, I specifically acknowledge that I have been advised of the facts and matters set below, and I agree as follows:

I have informed the practitioner that I am of the age of 18 or above.

I am currently not pregnant and/or nursing.

I am not under the influence of drugs or alcohol.

I have informed the practitioner of any and all of my known allergies. I acknowledge that it is not always reasonably possible to determine in advance whether I might have an allergic reaction to any of the needle, metal jewelry, topical preparations, or processes used in the procedure; and I agree to accept the risk that such reaction is possible.

I do not suffer from medical or skin conditions such as, but not limited to: keloid/hypertrophic scarring, psoriasis at the site of the piercing, or any open wounds or lesions at the site of the piercing.

I acknowledge that complications as a result of the body piercing procedure may occur, particularly in the event that the post-procedural instructions are not followed, and accept full responsibility for such complications.

I realize that my body is unique and neither Alis Volat Jewelry can predict how my skin may react as a result of the procedure.

I understand that Alis Volat Jewelry cannot predict the results in advance and cannot guarantee and has not represented that the results will be as I desire. I understand and fully accept the risks associated with this procedure and hold Alis Volat Jewelry harmless from same.

I understand that the body piercing procedure can result in nerve damage and bone loss (in cartilage areas).

I understand that there is a possibility I might feel lightheaded or dizzy during or after the body piercing procedure.

I agree to immediately notify the body piercer in the event I feel lightheaded, dizzy and/or faint before, during, or after the body piercing procedure.

I consent to the admittance of authorized observers to the procedure(s) for the purpose of education or assistance.

I consent to any relevant photographs being taken both before and after the procedure, to document procedure,and to display its capabilities and results strictly for social media/marketing purposes and internal use of only Alis Volat Jewelry and its owners.

I have read and understand the contents of each statement above. I acknowledge that this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent I am of sound mind and capable of making independent decisions for myself. I agree that I have been given the full opportunity to ask any and all questions regarding the piercing and the procedure and that all of my questions have been answered to my full satisfaction. I hereby release and forever discharge and hold harmless Alis Volat Jewelry and its owners, managers, technicians, and affiliates from any and all claims, damages or legal actions arising from or connected in any way with my body piercing procedure, to the fullest extent allowed by the law.

Location of Piercing #1

Location of Piercing #2

Location of Piercing #3

Date

Please sign your name here by entering your first & last name.