Stax Piercing Consent Form

CONSENT FORM
Client Information
Legal Name*

First NameLast Name
Preferred Name (Optional)
Pronouns*
Age*
Date of Birth*

MonthDayYear
Phone Number*
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Piercer*
Piercing Type:*
(Navel, Helix, Lobes. etc.) WE DO NOT OFFER SURFACE/DERMAL OR GENITAL WORK AT THIS TIME
Have you been pierced by us before?*

YesNo
Have you eaten in the last 4 hours?*

YesNo
Are you under the influence of drugs or alcohol?*

YesNo
Please add a photo of your valid ID. Must be a government issued, photo ID: Driver License, State ID, or Passport.*

Cancelof
Please Read and Initial

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions I might have about obtaining a body piercing from STAX Piercing, and that all questions have been answered to my full satisfaction. I acknowledge that I have been advised of the facts and matters set forth below by my initials I agree to the following:
I am the person on the legal ID presented as proof that I am 18+ years of age.*
INITIALS
I do not have any physical, mental, or medical conditions which may affect my wellbeing as a result of my decision to receive a body piercing at this time. *
INITIALS
I acknowledge that it is not reasonably possible for the piercer or any representative of STAX Piercing to determine whether I might have an allergic reaction to the metals, solutions or processes used for/during my body piercing procedure, and I agree to accept the risk that such a reaction is possible. *
INITIALS
I acknowledge that an infection is always possible, particularly in the event that I do not take proper care of my body piercing. I also agree to follow all instructions concerning the care of my piercing while it is healing, and will receive written instructions on the aftercare of my piercing. *
INITIALS
I understand that there is potential for adverse healing (such as keloid formation or hypertrophic scarring) that may only be removed by surgical procedure, which may leave permanent scarring and/or disfigurement.*
INITIALS
I hereby give my piercer permission to copyright and/or use and/or publish photographic portraits of pictures of me or in which I may be included in part of reproductions thereof made through any media of art, advertising, or any other lawful purposes whatsoever. I waive any right I may have to inspect and/or the finished product or the use to which it may be applied. *
INITIALS
I agree to release and forever discharge and hold harmless of STAX Piercing or any representative or subcontractor from any and all claims, damages, or legal actions arising connected in any way with my piercing, or the procedure and/or conduct used in the application of my piercing. However, if I feel I have a dispute that cannot be resolved by directly with STAX Piercing or its representatives, then I agree to submit to binding arbitration by a retired judge in the resident county.*
INITIALS
I acknowledge that I have been given adequate opportunity to read and understand this document in its entirety, and I understand that I am signing a legally binding contract.*
INITIALS
I understand that all jewelry and piercing or aftercare related items or accessories are FINAL SALE and that no refunds or exchanges will be offered. *
INITIALS
Please check any of the following conditions that may apply:*

COVID 19/Coronavirus (or exposure)Fainting/DizzinessScarring/KeloidsPregnant/NursingNone
Please list any allergies, diseases, conditions, medications (including antibiotics prior to dental or surgical procedures) or any known illnesses below. If none, write "none."*
Signature*
Today's Date*
Should be Empty:

CONSENT FORM

Client Information

Please Read and Initial