Laughing Buddha MINOR Piercing Release Form

What would you like us to call you (the minor)?

Preferred name

Phone Number

Please enter a valid phone number.

Legal Name of MINOR

First NameLast Name

Birth Date of MINOR

Date

PARENT/GUARDIAN Legal Name

First NameLast Name

Photo/Copy of PARENT/GUARDIAN Identification

Please upload a photo of your driver's license, or other official state or federal ID.

Photo/Copy of MINOR BIRTH CERTIFICATE

Please upload a photo of the minor's birth certificate.

Consent:

I, being the Parent/Guardian of the minor named above, hereby consent to a piercing, to be conducted by Laughing Buddha, or any agent or employee of the same as follows:

I acknowledge by signing this release that I have been given full opportunity to ask any and all questions that I may have and that all my questions have been answered to my full and total satisfaction. To endure the efficiency of healing, I will inform Laughing Buddha of any conditions, medical or otherwise, which may impair the full and proper healing of my piercing.

Do you consent?*

I consent.

Please confirm the following:

We have valid legal photographic identification in the form of a valid U.S. driver’s license, state-issued identification card, military identification, passport or other, AS WELL AS the minor’s birth certificate, proving the minor's age and relationship to parent/guardian and that we have exhibited said identification to Laughing Buddha prior to being pierced.*

I confirm.

I fully understand, acknowledge and agree that Laughing Buddha is not and shall not act in the capacity of a health care provider or medical professional with respect to the piercing or any aftercare provided.*

I confirm.

I fully understand there will be physical limitation on certain activities during healing such as bathing, recreational water activities, gardening, and contact with animals for a period of time.*

I confirm.

I acknowledge and understand that by having this piercing performed I am making a permanent change to my body which cannot be undone. I further acknowledge and understand that there have been no claims or guarantees made about the ability to undo any of the permanent changes that I have consented to be made by this piercing.*

I confirm.

I will follow the written and oral aftercare instructions and procedures outlines and provided to me until the healing of the piercing is complete.*

I confirm.

I will seek professional medical attention in case the following signs and symptoms of infection should occur, including but not limited to; redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent (pus) drainage from the procedure site.*

I confirm.

The undersigned for himself or herself, the heirs, successors, representatives as assigns hereby forever waives releases and discharges Laughing Buddha Body Piercing, their agents, employees, representatives, and other organizations affiliated with this studio and any and all of their heirs, successors or assigns (hereinafter referred to as Releasees.)

The undersigned further agrees to indemnify and do indemnify the Releasees from any and all claims demands, actions, liability and/or damages whatsoever performed under this agreement. The indemnification shall include, but shall not be limited to any and all attorney fees and costs incurred.

I have read and understand this entire document. I understand that it contains release of all claims, waiver of liability, my assumption of all risk, and an agreement for indemnification.

I declare under penalty of perjury under the laws of the state of California that the foregoing is true and correct and that I voluntarily sign my name evidencing my acceptance of all the above provisions.

Signature

Email Address:

example@example.com