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WAIVER, RELEASE & CONSENT TO PIERCING
Legal Name
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First Name
Last Name
Today's Date
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Month
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Day
Year
Date
Appointment Date
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Month
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Day
Year
Date
Preferred Name/Pronouns
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DOB
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drivers License No.
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Phone #
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
My Piercer's Name
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I hereby certify that I freely and voluntarily submit to this body piercing procedure after receiving both oral and written notification of the health risks associated with this piercing which includes pain, bleeding, swelling, infection, scarring and nerve damage. I also certify that I have received both oral and written piercing aftercare instructions.
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Yes
No
I confirm TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Piercers and the Piercing Studio from all liability whatsoever.
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Yes
No
I confirm the Piercer and the Studio have given me instructions on the care of my piercing while it’s healing, and I understand them and will follow them. I understand that this type of piercing usually takes up to three months to heal. I acknowledge that it is possible that the piercing can become infected, especially if I do not follow the instructions given to me. (Aftercare instructions will be given during your appointment)
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Yes
No
I confirm I do not have diabetes, epilepsy, hemophilia, a heart condition, nor do I take blood thinning medication. 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, have taken the prescribed preventive regimen antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. I am not pregnant or nursing. I do not have mental impairment that may affect my judgment in getting the tattoo. I am not under the influence of drugs or alcohol.
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Yes
No
If I suffer from hepatitis, or any other communicable disease, I have informed the piercer of this fact and I have been advised of any procedures necessary to promote the satisfactory healing of my piercing.
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Yes
No
I confirm I do not have medical or skin conditions such as but not limited to keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.
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Yes
No
I confirm I have advised the piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.
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Yes
No
I confirm I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and I agree to follow all of them while my piercing is healing. I understand I will be pierced using appropriate instruments and sterilization.
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Yes
No
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable to 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. This document contains all representations made and any attempt to alter or amend must be in writing and signed by both the client and a representative of the Piercer and Studio. I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this agreement. HEALTH RISK AND AFTERCARE NOTIFICATION VERIFICATION I hereby certify that I freely and voluntarily submit myself to this body piercing procedure after receiving both oral and written notification of the health risks associated with this piercing which includes pain, bleeding, swelling, infection, scarring and nerve damage. I also certify that I have received both oral and written piercing aftercare instructions. I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.
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Yes
No
We love capturing and sharing the beautiful jewelry and moments created here at Opalescent Studio. With your permission, we’d like to take photos and/or videos of your jewelry for use on our social media, website, and promotional materials.By signing below, you agree that:• Opalescent Studio may use photos/videos of you and your jewelry for marketing and promotional purposes (such as Instagram, Facebook, TikTok, or our website).• You will NOT receive compensation for the use of these images.• You may request at any time that we stop using your image in future posts.Your comfort and privacy matter to us! If you’d prefer not to have your photo shared, just let us know — it won’t affect your appointment or experience in any way.
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Yes
No
Participant Signature
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Date
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Month
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Day
Year
Date
Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone #
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Please enter a valid phone number.
Format: (000) 000-0000.
Please upload a photo of your driver’s license
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