PIERCING CONSENT FORM

I,   First Name*   Last Name*   , agree to the following:

I am aware of the risks associated with piercing procedures. I understand that these risks, known and unknown, can lead to injury including but not limited to: infection, scarring, allergic reactions, latex gloves. I wish to proceed with tattoo procedure and freely accept all outcomes that may arise from tattooing. I waive and release the technician from all liability.  
Initials*   

The technician has given me full opportunity to ask any question about the piercing procedure and application. All of my questions, if any, have been answered to my full and total satisfaction.  Initials*   

The technician has given me instructions on the aftercare of the piercing. I acknowledge that infection is possible, particularly if I do not follow the instructions given to me. If re-piercing is needed due to my own negligence, I agree that the work will be done at my own expense..Initials*   

I am not under the influence of alcohol or illegal drugs, and I am voluntarily submitting to be pierced by the technician without duress or coercion.Initials*   

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, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as piercing. I do not have a mental impairment that may affect my judgement in getting the piercing. I have disclosed any and all medical conditions to my technician that may affect the piercing procedure. Initials*   

I am pregnant or nursing.Yes   No*      
If I am pregnant or nursing, I am aware of the risks stated above and waive liability.   
Initial   

I release the right to any photographs/videos taken of me and the procedure and give consent in advance to their reproduction in print or electronic form.Initial*   

I agree that the technician has a no refund policy on tattoos, and will not ask for a refund for any reason whatsoever. Initials*   

I agree to reimburse the piercing technician for any attorneys' fees incurred in any legal action I bring against the technician. I agree that the courts located in the County of Fairfield within the State of Connecticut 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.Initials*   

I acknowledge that I have been given adequate opportunity to read and understand this document. I am signing a legal contract waiving certain rights to recover damages against the technician. I understand that the technician has the right to terminate the appointment should the document should not be signed within (7) days of deposit payment without a refund.Initials*   

I declare that I am of legal age (and have provided valid proof of age and identification above) and am competent to sign this agreement. If I am not of legal age, I am accompanied by an adult of legal age who will sign below.

First Name*   Last Name*   
Email*   
   Phone Number*   
Date*   
Date of Birth*   

Signature*   

I want to receive promotions and correspondence from Ink Side Out Tattoo Lounge
Text   Yes   No*   
Email   yes   No*      

I am allergic to:
Latex   Yes   No*   
Adhesive   Yes   No*   
Lidocaine/Numbing   yes   No*