Minor Piercing Consent Waiver

Minor Piercing Consent Waiver

For Clients under 18, a parent or legal guardian must be present to sign.
Parent/ Guardian Photo ID:*

Cancelof
Minor's Birth Certificate or Documentation proving legal guardianship of the minor:*

Cancelof
Client Information
Legal Name*

First NameLast Name
Name They Go By

First NamePronouns
Birth Date*

MonthDayYear
Date
Parent/ Guardian Information
Legal Name*

First NameLast Name
Relationship to Client*
i.e. mother, father, legal guardian, etc.
Email*
example@example.com
Pre-Procedure Questionnaire
Is your child experiencing flu symptoms at the time of the appointment? (Active illness while receiving a piercing will create complications during the initial healing.)*

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

YesNo
Does your child have any skin conditions affecting the piercing site? (i.e. eczema, psoriasis, rash, etc.)*
If yes, please identify the condition.
Does your child have any relevant allergies or sensitivities? (i.e. latex, iodine, metals, etc.)*
If yes, please specify the allergy and severity.
Do any of the following conditions apply?*
*

I understand, that like any invasive procedure, body piercing may involve possible health risks. These risks may include: Pain, bleeding, swelling, infection, scarring of the area, and nerve damage. Unsterile equipment and needles can spread infections diseases; it is extremely important to be sure that all equipment is clean and sanitary before use. I may not be able to donate blood either temporarily or permanently, depending on the guidelines of the blood donation service I use.
*

I understand that the body art practitioner should: Properly cleanse the area before piercing; use sterilized equipment; use sterile techniques; and provide information on the aftercare.
*

Both the legal guardian and minor consent to the piercing procedure and acknowledge that it will result in a permanent change to their appearance. Both individuals understand that their skin may not be restored to its pre-piercing condition even after its removal.
*

I will help my child follow aftercare instructions given to us by Rubi's Piercing to the best of my ability. I understand that straying from the recommended aftercare instructions may cause complications during the healing process of my piercing.
*

If there is any injury, infection, or complication, I will notify this establishment and the Watertown Public Health Department at (617) 972- 6446.
*

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 the piercing. I release all rights to any photographs taken of my child and the piercing and give consent in advance to their reproduction in print or electronic form.*

YesNo
Signature*
Signed Date*

MonthDayYear
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.
Should be Empty:

Minor Piercing Consent Waiver

Client Information

Parent/ Guardian Information

Pre-Procedure Questionnaire