Piercing Consent & Waiver Form

Email

example@example.com

Phone Number

Area CodePhone Number

Phone Number

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

Date of appt.

Date

Front of Driver License (18+ or Parent/Guardian only no minors)

Tap Browse to take photo

Back of Driver License

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Piercing option

I.e.Piercing options: lobe, helix, conch, flat, midi, tragus, stacked, constellation, forward & floating helix

Any Heart Conditions

Are you on any blood thinners

Are you currently Pregnant or breastfeeding (Legally must answer truthfully)

Any Bloodborne illnesses/diseases

Select Bloodborne illnesses/diseases (Pick does not apply if no bloodborne illness)

(REQUIRED BY LAW TO ANSWER CORRECTLY)

(LEAVE BLANK IF NONE) Medical conditions not listed above (NOTE: MUST SPEAK WITH ARTIST IF YOU ARE LISTING ANY CONDITIONS)

I.e. diabetes, epilepsy, Blood Clotting Disorders, Immunosuppressive Diseases or Medications.

Any known allergies?

Allergies:

LEAVE BLANK IF NONE

Age of person getting service:

(must be 18 or older. If parent or guardian please list child’s age)

I acknowledge I have been advised of the facts and matters set forth below and I agree as follows:

If the person whom is getting service has diabetes, epilepsy, hepatitis, hemophilia, HIV-AIDS or any other communicable disease, heart condition or take medicine which thins the blood I have advised my tattooer/Piercer.
The person getting service is not pregnant or nursing or not under the influence of alcohol or drugs.
I or Gardian of minor acknowledge it is not possible for the representatives and employees of this location to determine whether I might have an allergic reaction to the pigments or processes used in my Piercer, and I agree to accept all the risk that such a reactionor issue is possible.
I or Gardian of minor acknowledge that infection is always possible as a result of the obtaining of a Piercing, particularly in the event that I or Gardian of minor do not take proper care of my Piercing. I or Gardian of minor agree to follow aftercare instructions while my Piercing is healing.
I or Gardian of minor acknowledge that a Piercing is a permanent change to appearance and do not hold my Piercer liable for or of the ability to later change or remove my Piercing.
I or Gardian of minor acknowledge I am over the age of eighteen and that I have truthfully represented to my Piercer that the obtaining of a Piercing is by my choice alone. If Minor, I as the gardian consent for service and will not hold PIPER-jade lilable for issues during or after service is completed.
I fully understand the Piercer does not act as a medical professional.
I agree to release and discharge any employee at PIPER-jade from any and all claims, damages, or legal actions arising from or connected to Piercing and the procedure used in the application of my Piercing.
I consent to the application of the piercing. My artist and I recognize that I may revoke this consent at any time before or during the service procedure.
I fully understand that any service at PIPER-jade is FINAL SALE. No refunds or replaments will be provided on any including earrings. I understand it is at the discretion of PIPER-jade to review any claims or to provide any discounts.

Signature

By checking “Yes” you agree to all terms stated above.

Electronic signature

First NameLast Name