Downsize Waiver
Client Information
Legal Name
*
First Name
Last Name
Name you Go By
First Name
Pronouns
Email
*
example@example.com
Pre-Procedure Questionnaire
Piercing Type(s):
*
Please specify all piercings you need changed.
Was your piercing performed at our studio? If no, I understand Rubi's Piercing may not carry compatible jewelry and may not be able to help with my downsize.
*
Yes
No
Is the piercing experiencing irritation?
*
If yes, please specify
Do you have any relevant allergies or sensitivities? (i.e. latex, iodine, metals, etc.)
*
If yes, please specify the allergy and severity.
*
I consent to my downsize procedure and understand, while rare, it may cause slight discomfort.
*
I understand that all information disclosed will be kept confidential and a copy will be provided to me upon request.
*
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
I consent to Rubi's Piercing capturing photos of my piercing. I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form.
*
Yes
No
Client Signature (If under 18, Legal Guardian will sign)
*
Signed Date
*
-
Month
-
Day
Year
Date
*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record.
Submit
Submit
Should be Empty: