Consultation Form

Consultation Form
CLIENT INFORMATION
Name:
Date of Birth:

MonthDayYear
Date
Address:
City:
State:
Phone #:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact:
Emergency Contact Phone #:
Format: (000) 000-0000.
How did you hear about Evening Dogwood?:
List any medication and medical conditions that could impact your ability to receive the jewelry:
ACKNOWLEDGEMENT
I completed the above form to the best of my knowledge. I have had the opportunity to ask any questions and have received satisfactory answers. I will inform the jeweler of any changes to the above information. I am over the age of 18 and consent to the procedure. If I am under the age of 18, a parent or guardian must sign. I will not hold the jeweler liable for any issues not disclosed at the time of my service or any adverse effects from the procedure.
CLIENT/ PARENT/ or GUARDIAN NAME:
CLIENT/ PARENT/ or GUARDIAN SIGNATURE:
DATE:

MonthDayYear
Date

WAIVER
Permanent jewelry is a process that involves the use of welding the jewelry together while on your body. The procedure is generally painless and is performed with your safety in mind. This consent form is intended to inform you of the risks of the procedure and to obtain your informed consent for the procedure.
I understand that although rare, an allergic reaction to the jewelry can occur:
I understand that the welding procedure does have some risks including but not limited to potential allergic reaction, irritation, discomfort, burns, and scarring:
I understand my jewelry is covered under a 30 day warranty and the jeweler will re-weld a broken chain free of charge within those 30 days. After 30 days it will be up to the jeweler if a fee is required. (local residents only):
I understand ALL SALES ARE FINAL. However, if there is a defect in the jewelry including the chain, charm(s), or connector(s) you will receive a replacement free of charge FIRST. If a replacement is not possible, then 2/3 of the sale will be refunded. The jeweler must be notified as soon as possible so that the situation can be rectified within a timely manner.
I agree to the jewelry care instructions recommended by the jeweler:
I understand that although this jewelry is intended to be “permanent”, durable, and long-lasting; the length of wear can vary depending on my physical activity, if any connectors/charms were chosen, and other various factors:
I understand that there may be some instances where I will be required to remove my jewelry including but not limited to medical procedures such as an MRI, X-Ray, or surgery. Under such circumstances I understand that the jewelry can easily be removed with scissors and reattached by the jeweler at a later date for free:
I give the jeweler permission to photograph my jewelry and procedure for their own marketing and promotional purposes:
ACKNOWLEDGEMENT
I have completed the above form to the best of my knowledge. I have had the opportunity to ask any questions and have received satisfactory answers. I understand the risks and potential side effects associated with the permanent jewelry procedure. I understand that the results of the procedure are not guaranteed and may vary from person to person. I am over the age of 18 and consent to the procedure. If I am under the age of 18, a parent or guardian must sign. I will not hold the jeweler liable for any issues not disclosed at the time of my service or any adverse effects from the permanent jewelry procedure.
CLIENT/ PARENT/ or GUARDIAN NAME:
CLIENT/ PARENT/ or GUARDIAN SIGNATURE:
DATE

MonthDayYear
Date
Should be Empty:

Consultation Form

CLIENT INFORMATION

ACKNOWLEDGEMENT

WAIVER

ACKNOWLEDGEMENT