Piercing Procedure Waiver

PIERCING - I N T A K E F O R M / W A I V E R
Date

MonthDayYear
Date
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 CodeCountry
Date of Birth*

MonthDayYear
Date
Are you Under 16 Year Old?*

YESNO
Emergency contact*

First NameLast Name
Emergency contact Phone Number*
Please enter a valid phone number.
MEDICAL HISTORY
PLEASE CHECK IF ANY CONDITIONS LISTED BELOW APPLY TO YOU:

DiabetesHemophiliaSkin Sensitivity to soap or disinfectantSkin LesionsSeizuresEpilepsyFaintingBlood PressureOther
Do you have additional allergies to Metal,Soaps,Cosmetics or Alcohol?*

YESNO
Are you currently pregnant?*

YESNO
Are you currently taking medication that thins the blood?*

YESNO
Are you currently under the care of a physician?*

YESNO
Are you currently under influence of drugs and alcohol?*

YESNO
Do you have any communicable disease?*

YESNO
Do you have any medical or skin conditions that might affect the outcome of this procedure?*

YESNO
Please INITIAL in the boxes provided after reading to show you understand each provision. Feel free to ask any question regarding this wiaver.
I,First Name* Last Name* acknowledge that by signing this waiver that I have been given full opportunity to ask any and

all questions which I might have about obtaining a piercing from INK ME TORONTO All of my questions have been answered to my fullest and total

satisfaction. I specifically acknowledge that I have been advised of the facts and matters below and I agree as follows
I am free of communicable diseases.*

I agree to this statement
I understand that the employee of INK ME TORONTO cannot determine if I might have an allergic reaction to the piercingprocess or jewelry, and I assume the risk.*

I agree to this statement
I have received written instructions for proper piercing care and understand the importance of following them.*

I agree to this statement
I acknowledge the possibility of infection if proper aftercare instructions are not followed.*

I agree to this statement
I understand that piercing is a permanent change to my appearance and may scar when removed.*

I agree to this statement
I consent to the piercing procedure and any necessary actions by INK ME TORONTO employees.*

I agree to this statement
I release INK ME TORONTO and its employees from any claims or damages related to my piercing.*

I agree to this statement
I consent to the publication of photos of my piercing by INK ME TORONTO.*

I agree to this statement
I confirm that I am 16 years old (18 for genital piercing) and competent to sign this agreement. If not, my parent or legalguardian will sign on my behalf, and they understand and agree to this agreement.*

I agree to this statement
I have read, understood, and agree to abide by the shop's rules.*

I agree to this statement
I confirm that all information provided is true and understand the consequences of providing false information.*

I agree to this statement
I have read and understood this agreement, and I agree to its terms.*

I agree to this statement
I agree to receive promotional and aftercare emails from Ink Me Toronto.*

YES
**PLEASE ASK YOUR ARTIST ABOUT THE PRICE OF YOUR PIERCING BEFORE BEGINNING OF THE PROCEDURE - it is your

responsibility to confirm the price of the Piercing and we assume no responsibility for misunderstanding in this regard.
Signature*

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PARENTAL CONSENT (IF 15 OR YOUNGER)
Name

First NameLast Name
RELATION TO CLIENT

PARENTGUARDIAN
Phone Number
Please enter a valid phone number.
Signature

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FOR OFFICE USE ONLY! DO NOT FILL
PIERCER

SAMITNAMITA
PROCEDURE
PAID IN FULL

YESNO
DATE PROCEDURE COMPLETED

MonthDayYear
Date
NOTES
Should be Empty:

PIERCING - I N T A K E F O R M / W A I V E R

MEDICAL HISTORY

Please INITIAL in the boxes provided after reading to show you understand each provision. Feel free to ask any question regarding this wiaver.

PARENTAL CONSENT (IF 15 OR YOUNGER)

FOR OFFICE USE ONLY! DO NOT FILL