Old West Body Piercing Form

Full Name*

First NameLast Name

Age*

Date of Birth*

Date

Phone Number*

Format: (000) 000-0000.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of the body piercer helping you today*

What brings you in today?

If you have any allergies and or skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.) please identify the condition below

If yes, please identify the condition.

I have trustfully represented to my piercer that I am at least 18 years old. I acknowledge that the obtaining of a piercing is by my choice alone. To my knowledge I do not have any physical, mental, or medical impairments or disabilities which might affect my well being as a direct or indirect result of my decision to have a body piercing. I consent to the administration of the body piercing and to any actions or conduct of the piercer, contractors, or employees of Old West Body Piercing that is reasonably necessary to perform the piercing procedure.*

Acknowledge

I acknowledge I have eaten within the last 4 hours, that I am not under the influence of drugs or alcohol, and I have not taken any form of aspirin, ibuprofen, or anticoagulants within the last 24 hours.*

Acknowledge

I am not pregnant or nursing. I do not have or suffer from epilepsy, hemophilia, narcolepsy, dizziness, fainting, or any form or seizure causing condition that could interfere with the procedure. I do not suffer from any heart conditions or take medication which thins the blood. I am not currently taking any antibiotics or Accutane. I have informed my body piercer of any conditions that compromise my immune system and any conditions such as diabetes that might hamper healing of the piercing.*

Acknowledge

If I suffer from hepatitis or any other communicable disease, I have informed the body piercer and I have been advised of any procedures necessary to promote the satisfactory healing of my tattoo. Artists will never refuse service based on any communicable disease.*

Acknowledge

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

Acknowledge

I have informed my body piercer of any allergies to latex, adhesives, metals, soaps, and or medications. Body piercers do sometimes use latex gloves for procedures. Nitrile gloves can be used if requested. I acknowledge it is not reasonably possible for the body piercer to determine whether I might have any allergic reactions to the piercing, soaps, iodine, or other materials used in the preparation and or process involved in getting a piercing and I further acknowledge that a reaction to the piercing and or other materials is possible, even after the piercing has healed.*

Acknowledge

I acknowledge that there may be side effects from this procedure, including swelling, and or bruising. Infection and or irritation is always possible as a result of obtaining a body piercing. I will receive aftercare instructions upon completion of my piercing and I will follow all instructions while my piercing is healing. If I have any issues or concerns with the piercing I will contact my body piercer.*

Acknowledge

I understand that every care has been taken to ensure that this procedure has been carried out in a hygienic manner, and I will be pierced using appropriate instruments and sterilization process. Furthermore, I understand the aftercare of the body piercing is my sole responsibility*

Acknowledge

I acknowledge that I have seen the placement of the body piercing and have agreed to it with the body piercer. If later I decide that I want something else or to change the placement of the body piercing that will be done at the standard rate if they are possible.*

Acknowledge

I acknowledge that the body piercing will result in a permanent change to my appearance and that my skin may not be restored to its pre-piercing condition even after its removal.*

Acknowledge

I give consent to allow Old West Body Piercing and its team members the use of photography and videography which may include myself & or parts of my body for marketing and social media purposes*

Acknowledge

Release*

I consent to allow one of the team members at Piercings by Cooley LLC or Old West Tattoo/Sovereign Rescources LLC to provide me with a body piercing. In consideration of doing so, I hereby release Piercings by Cooley LLC, Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management, its independent contracted artists, affiliates, and or agents from all manner of liabilities, claims, actions and/or demands, in law or in equity, which I or mey heirs have or might have now or hereafter by reason of complying with my request to be pierced. I fully understand that any independent contractor, employee, artist, or agent of Piercings by Cooley LLC, Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Managment, when performing body piercing, does not fact in the capacity of a medical professional. The suggestions made by an artist or agent of Piercings by Cooley LLC, Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management, are just suggestions that are not to be misconstrued or as substituted for advice from a medical professional. I understand I will be pierced using appropriate instruments, procedures, and techniques. To ensure proper healing of my body piercing, I agree to follow the aftercare procedures outlined in the body piercing aftercare instructions, until the healing is complete. I understand that this type of body piercing usually takes 4 to 6 months, or longer to heal. I willing submit to these procedures, with a full understanding of possible complications such as, but not limited to, infection, allergic reaction, and/or rejection of jewelry. I have received a copy of the body piercing aftercare, which I have read and fully understand and hereby assume full responsibility for aftercare and cleanliness. I understand that by having this body piercing procedure performed I am making a permanent change to my body and no claims have been made regarding the ability to undo the changes made. I agree to wave and release and forever discharge and hold harmless to the fullest extent of the law, Piercings by Cooley LLC, Old West Tattoo, Sovereign Resources LLC, Sovereign Asset Management, ownership , artists, independent contractors, our estate, heirs, executors, or assigns may have for personal injury or otherwise, including any direct and or consequential damages, which result or arise, whether cased by the negligence or fault of either the body piercer, tattoo shop, or otherwise, and all owners, contractors, employees from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or the procedure and conduct used in my piercing.I consent to any actions or conduct of the representatives, contractors, and or employees of Piercings by Cooley LLC, Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management necessary to perform the aforementioned procedure.I acknowledge that a body piercing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove any scarring, marking, or the like.I acknowledge that Piercings by Cooley LLC, Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management LLC, any of its affiliates, contractors, artists, nor employees offer refunds

Aftercare*

I understand that any medical or skin condition such as but not limited to: acne, scarring, eczema, psoriasis, freckles, moles, rash, and or sunburn in the area to be tattooed that may interfere with your tattoo and or the healing process of said body piercingI understand that I might get an infection if I don't follow the instructions given to me in regards of taking care of my piercingI understand that I need to take care of the piercing by following the instructions given to me by the staff of Piercings by Cooley LLC, Old West Tattoo, Sovereign Resources LLC, and or Sovereign Asset Management LLCI understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my piercing.I acknowledge that both written and verbal instructions regarding risk, outcome, and aftercare were given to me

*

I confirm that the information I provided in this document is accurate and true.

How did you hear about us?

Signed Date*

Date

Client Signature*

Upload your photo ID below. Please present your photo ID to an Old West staff member before uploading.*

Body Piercing Consent Form

Client Information

Acknowledgment and Waiver