Piercing Client Consent Form

Mountain Coast Ink Client Piercing Consent Form
Date*

MonthDayYear
Date
Legal Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License Number*
Driver's License Photo*

Cancelof
Is the client a minor (under 18)?*

YesNo
Parent or Guardian Legal Name

First NameLast Name
Parent or Guardian Driver's License Number
Parent or Guardian Driver's License Photo

Cancelof
Please Initial Below Each Provision - Thank You

PLEASE NOTE- Providing FALSE information and /or ID is a CRIME
Piercing Artist*
Piercing Artist
Artist Email
example@example.com
In consideration of receiving a piercing from at Mountain Coast Ink, together with its employees, apprentices and agents, Mountain Coast Ink, I agree to the following:
That I (your legal name) blanks*have been fully informed of the inherent risks, associated with getting a piercing. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection or scarring. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept and expressly assume any and all risks that may arise from a piercing.
Initials*
TO WAIVE AND RELEASE to the fullest extent permitted by law Type a label and Mountain Coast Ink from all liability whatsoever, for any and all claims or causes of action that I, 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 piercing, whether caused by the negligence or fault of either Type a label or the Mountain Coast Ink, or otherwise.
Initials*
That both Mountain Coast Ink and Type a label have given me the full opportunity to ask any and all questions about the application of my piercing and all of my questions have been answered to my total satisfaction.
Initials*
Type a label and Mountain Coast Ink have given me instructions on the care of my piercing while it’s healing, and I understand them 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.
Initials*
I am not under the influence of alcohol or drugs, and I am voluntarily submitting to a piercing by Type a label without duress or coercion.
Initials*
In the event that jewelry comes out, the client is responsible for the cost of new jewelry, unless it has been less then 48hrs.
Initials*
I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. I am not neurologically or immune compromised. I do not have any other medical or skin condition that may interfere with the application or healing of the tattoo. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as tattooing and piercing. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgment in getting the tattoo.
Initials*
I do not have allergies or advers reactions to latex pigments, dyes, disinfectants, soaps or metals.
Initials*
I am not pregnant or nursing.
Initials*
I do not have any of the following blood borne illnesses; HIV, Hepatitis B, or Hepatitis C.
Initials*
I release all rights to any photographs taken of me and the tattoo and give consent in advance to their reproduction in print or electronic form. (If you do not initial this provision please advise and remind Type a label and Mountain Coast Ink, NOT to take any pictures of you and your completed tattoo).
Initials*
I agree to reimburse Type a labeland Mountain Coast Ink for any attorney fees and costs incurred in any legal action I bring against either Type a label or Mountain Coast Ink and in which either Type a label or Mountain Coast Ink is the prevailing party. I agree that the that the courts of COLORADO in JEFFERSON COUNTY shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.
Initials*
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 I understand that I am signing a legal contract waiving certain rights to recover Type a label and Mountain Coast Ink.
Initials*
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.
Initials*
I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Initials*
Client Legal Name*

First NameLast Name
CLIENT SIGNATURE:
CLIENT SIGNATURE*

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In Case of Emergency Contact Colorado State Dept. of Health #: 303-692-2000
TO BE COMPLETED BY THE STUDIO ARTIST:

(for Mountain Coast Ink use)
ARTIST NAME
Amount Due
Misc. Costs
Gratuity
Total
Form of Payment

CashChargeVenmo
Tool:
Date:

MonthDayYear
Date
Tool:
Date:

MonthDayYear
Date
Tool:
Date:

MonthDayYear
Date
Tool:
Date:

MonthDayYear
Date
Needle Lot #
Expiration Date:

MonthDayYear
Date
Design:
Piercing:
ARTIST SIGNATURE:

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Date:

MonthDayYear
Date
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If you are filling out the form outside of the shop please do the following:

After you click on Save, you will be asked to create a Jotform account. Please DO NOT DO SO. Instead click on Skip Create an Account and enter mountaincoastink@gmail.com as the email address and then click on the Send button. If you do not do so, you will have to fill out the form again when you arrive at the shop for your appointment. Thank you!

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Should be Empty:

Mountain Coast Ink Client Piercing Consent Form

Please Initial Below Each Provision - Thank You

CLIENT SIGNATURE:

TO BE COMPLETED BY THE STUDIO ARTIST: