Standard Release Form for Piercing Service
As required by the State of Florida - This is a release form for those over the age of 18, receiving piercing services at Beauty In Ink, LLC.
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
How old are you?
*
Race
*
Other
White
Black or African American
Hispanic or Latino
Asian
Native American or Alaska Native
Native Hawaiian or Pacific Islander
Mixed / Multiracial
Sex
*
Male
Female
EMERGENCY CONTACT INFO
Do not write 911
Name of Emergency Contact
*
First Name
Last Name
Relationship
*
Phone Number of Emergency Contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address of Emergency Contact
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Info
Use our recommendation or add your own physician details below
Insert Doctor or Walk In Clinic Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Release Form Questions & Acknowledgements
I am at least 18 years old, or I am accompanied by my mother, father, or legal guardian.
*
Correct
I don’t have a heart condition. I don’t have epilepsy. I haven’t had hepatitis within the past year. I am not a hemophiliac.
*
Correct
If I am HIV positive or have AIDS, hepatitis, or syphilis, then I will alert an employee of (Business Name) before any work takes place.
*
Correct
I am not under the influence of drugs or alcohol. I am not pregnant or nursing. I have eaten in the past 4 hours.
*
Correct
To my knowledge, I don’t have any physical, mental, or medical impairment or disability which might affect my wellbeing as a direct or indirect result of my decision to have tattoo-related work or a body piercing done at this time.
*
Correct
I agree not to sue Beauty In Ink LLC in connection with any and all damages, claims, demands, rights, and causes of action of whatever kind or nature, based upon injuries or property damage to, or death of, myself or any other persons arising from my decision to have tattoo-related work or body piercing done at this time, whether or not caused by any negligence of Beauty In Ink LLC.
*
Correct
I acknowledge that I have been given or will be given aftercare instructions before or after the appointment and I agree to follow all instructions concerning the care of my tattoo and/or body piercing while it is healing. I agree that any touch-up work needed, due to my own negligence, will be done at my own expense.
*
Correct
Being of sound mind and body, I hereby release any and all persons representing Beauty In Ink LLC of Boca Raton, Florida from all responsibility. I accept any and all responsibility myself for any consequences that might stem from my decision to have tattoo-related work or a body piercing done by Beauty In Ink, LLC.
*
Correct
I have been told and I am aware of the risks of getting a body piercing and/or tattoo. These risks include but are not limited to scarring, bruising, swelling, disfigurement, rejection, allergic reactions, irritation, and pain.
*
Correct
I understand that I am getting a body art procedure done in a safe, clean environment using sterile equipment. I understand that there are variables that Beauty In Ink, LLC cannot control while my body art is healing. It is my responsibility to keep my body art clean and follow all aftercare instructions. I understand that tattoos and/or body piercings are not guaranteed to heal; however, Beauty In Ink, LLC will, to the best of their ability, help me troubleshoot any problems that may occur during and after the healing process. This troubleshooting or advice does not take the place of the diagnosis of a medical professional.
*
Correct
I have been given verbal and written aftercare instructions and I understand them.
*
Correct
Do you have a history of bleeding disorders? If NO, type no, if YES, please write in details:
*
Do you have now or ever contracted Hepatitis A,B, or C or Syphilis or are HIV+? If NO, type no, if YES, please write in details:
*
Do you have any allergies including latex, metals, soaps, creams, medicines, etc.? If NO, type no, if YES, please write in details:
*
Drivers Licence #
*
UPLOAD DRIVERS LICENCE OR ID (FRONT OF CARD)
*
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UPLOAD DRIVERS LICENCE OR ID (BACK OF CARD)
*
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Signature Confirmation
*
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Next To - Informed Consent for Body Piercing Procedures
Informed Consent for Tattoo & Body Piercing Procedures
As required by the State of Florida - This is an Informed Consent Form for those over the age of 18, receiving piercing services at Beauty In Ink, LLC.
Placement of Body Piercing (i.e., Ear, Mouth, Stomach, etc)
*
I am fully aware of and accept the risks of receiving a tattoo or body piercing. These risks include but are not limited: a. Infection b. Rejection of the piercing c. Swelling d. Pain in the procedure area e. Misaligned placement due to the client moving during the procedure f. Nicks, scratches, scarring or other marks on the body, whether they are permanent or semi permanent in nature that may be the result of the tattoo and/or body piercing procedure g. Bleeding, drooling, spitting, vomiting, gagging, sneezing, loss of bladder control, loss of consciousness, loss of balance, tripping, falling and the consequences of the above-mentioned actions, whether they are intentional or unintentional. h. Oral body piercings including but not limited to the lip, tongue, tongue web, cheek, etc. will cause swelling at the body piercing area and can cause mild or severe dental problems such as teeth chipping or breaking, gum disease, gum recession and other dental problems
*
I consent
I understand that "I" will make every effort to successfully perform the tattoo and/or body piercing on the client. However, if the client is resistant to receiving the tattoo and/or body piercing, "Beauty In Ink,LLC" will try to perform the tattoo and/or piercing for no more than 5 minutes. After which time "Beauty In Ink,LLC" will cease to try to perform the tattoo and/or body piercing. I understand that once the procedure supplies are opened, I will be charged the full body piercing procedure price whether the client receives the tattoo and/or body piercing or not.
*
I consent
I understand that tattooing and/or body piercing is not an exact science. There are many unknown variables and not every tattoo and/or body piercing comes out perfect.
*
I consent
I understand that tattoos and/or body piercings are NOT guaranteed to heal. The tattoo and/or body piercing is being performed in a clean environment with sterile equipment. Anything that happens to the tattoo and/or piercing once it leaves the shop is the responsibility of the client.
*
I consent
I understand that I need to tighten the body jewelry at least once a month to ensure it stays in the skin. I understand that the natural movement of the body may cause the body jewelry to unscrew.
*
I consent
I understand and acknowledge that I was given the opportunity to inspect the drawing, stencil, body jewelry, and/or body piercing placement before the procedure and I agree that everything is exactly how I want it placed on my body. I understand that Beauty In Ink, LLC is not responsible if I decide I don’t not like the design, placement, or body jewelry once the procedure has begun.
*
I consent
I acknowledge that I have read this form in its entirety, and I agree to hold Beauty In Ink, LLC and the body piercer and/or tattoo artist completely harmless of any unforeseen consequence resulting from the body piercing and/or tattoo procedure.
*
I consent
Signature Confirmation
*
How did you hear about us?
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Referral
Blog or Article
Other
First time here?
Yes
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