Piercing Consent Form
I WANT YOU TO FEEL SAFE, COMFORTABLE, HAPPY, AND TAKEN CARE OF. PLEASE COMMUNICATE OPENLY WITH ME (LIZZIE) TO ENSURE I KNOW HOW TO HELP YOU STAY COMFORTABLE.
I fully understand that Elizabeth (Lizzie) Post, when performing a piercing, does not act in the capacity of a medical professional. The suggestions made by Lizzie are just suggestions. They are not to be constructed as, or substituted for advice from a medical professional. I understand that the piercing will be performed using appropriate techniques, instruments, and jewelry. I understand that infections can occur due to lack of proper hygiene. To ensure proper healing of my piercing, I agree to follow the written and verbal aftercare instructions that will be provided, until healing is complete. I understand that the piercing may take up to several months to heal properly.
I hereby give consent to Lizzie to perform a piercing and in consideration of doing so, I hereby release Lizzie of all liability
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Legal Name (Please add preferred name too!)
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First Name
Last Name
What piercing(s) are you in consideration of receiving today?
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Pronouns
Today's Date
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Month
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Day
Year
Date
I am 18 years of age or older, or have parental consent for this piercing
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Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Client Medical History
l acknowledge, by signing this agreement, that I have been given the full opportunity to ask any and all questions I might have about obtaining my piercing. I acknowledge that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and agree as follows:
Please select all that apply:
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Accutane/ Retin-A
Allergies to latex
Allergies to nitrile
Allergies to adhesives (glues, tapes, bandaids, etc)
Allergies to preservatives in saline solutions
Chemotherapy/ Radiation
Eating disorders
Eczema/psoriasis
Hormonal imbalance or extreme stress
Irritated/ Broken Skin
Iron deficiency
Pregnant or breast feeding
Thyroid Disease/ Medications
Herpes at the Procedure site
Diabetes
Hemophilia or any other bleeding disorder
Cardiac valve disease
None
Have you taken any blood thinning medications within the last 24 hours? (Including ibuprofen or aspirin)
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Yes
No
Have you eaten within the past two hours?
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Yes
No
Are you prone to fainting
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Yes
No
In consideration of receiving a piercing by Lizzie, I agree to the following:
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I will let my piercer know of any allergies to shea, mango and aloe butters, coconut, sunflower and rice bran oils, rosemary oleoresin, green Tea, vitamin E complex, mint arvenis essential oil, iodine, or nitrile.
I have been fully informed of the inherent risks associated with getting a piercing. Therefore, fully understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, tooth damage, abscesses, nerve damage. Having been informed of the potential risks associated with getting a piercing I wish to proceed with the piercing procedure and freely accept and expressly assume any and all risks that may arise from piercing.
I HAVE READ THE AGREEMENT ABOVE, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.
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I WAIVE AND RELEASE,
to the fullest extent permitted, by law Lizzie from all liability whatsoever. Including, but not limited to, any and all claims or causes of action that l, my estate, heirs, executors or assigns may have for personal injury or otherwise. Including any direct and/or consequential damages, which result or arise from the procedure of my piercing, whether caused by the negligence or fault of Lizzie, or otherwise.
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Lizzie has given me the full opportunity to ask any question about the procedure of my piercing. All of my questions, if any, have been answered to my total satisfaction.
Lizzie has given me instructions on the care of my piercing while it's healing. I understand and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. In rare cases risks associated with body art procedures can include fainting, vomiting, and infection including bacterial endocarditis for patrons with a heart condition.
If any re-piercing is needed due to my own negligence, I agree that the work will be done at my own expense.
I have not been under the influence of alcohol or drugs in the past 24 hours, and I am voluntarily submitting to be pierced by Lizzie without duress or coercion.
I do not suffer from diabetes, epilepsy, hemophilia, heart condition(s), nor do I take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure, application or healing of the piercing. I am not the recipient of an organ or bone marrow transplant or, if I am, have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the piercing.
I release the right to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (For assurance, if you do not agree to this provision, please inform Lizzie to NOT take any pictures of you and your completed piercing).
I hereby declare that I am of legal age (and have provided valid proof of age and identification) and I am competent to sign this agreement.
I agree that Lizzie has a NO REFUND policy on piercing and retail sales. I will not ask for a refund for any reason whatsoever.
I agree to reimburse Lizzie for any attorneys' fees and costs incurred in any legal action I bring against Lizzie. I agree that the courts located in the County of Salt Lake City within the State of Utah shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any dispute arising out of or related to this agreement.
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 grasp that l am signing a legal contract waiving certain rights to recover damages against Lizzie 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.
I am aware that Lizzie is in a shared space; therefore, if I cause a commotion (particularly screaming, yelling, etc) at any point during the piercing process, the procedure will immediately be stopped, and I will still be required to pay the full service fee.
I HAVE READ THE AGREEMENT ABOVE, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.
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Legal Name
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First Name
Last Name
Government Issued ID
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‼️⚠️THE BELOW SECTION IS NOT REQUIRED UNLESS A MINOR IS GETTING PIERCED⚠️‼️
please leave this section empty if you are not a parent accompanying a minor.
Signature Of Parent/Legal Guardian If Minor Is Receiving the Piercing
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Government Issued ID
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