Jewelry Change Consent Waiver
Client Information
Legal Name
*
First Name
Last Name
Name you Go By
First Name
Pronouns
Birth Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Pre-Procedure Questionnaire
Piercing Type(s):
*
Please specify all piercings you need changed.
Did you bring your own jewelry to be inserted today? If yes, I understand that Rubi's Piercing is not liable for any possible irritation to my skin caused by the jewelry I've provided. I understand that Rubi's Piercing cannot sterilize jewelry purchased elsewhere. I accept responsibility for ensuring my jewelry has been disinfected before insertion.
*
Yes
No
Are you experiencing flu symptoms at the time of your appointment?
*
Yes
No
Are you under the influence of any drugs or alcohol?
*
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.
Do any of the following conditions apply?
*
Please Select
None
Diabetes
Hemophilia
Any condition requiring blood-thinning medication
Anemia
Epilepsy
History of fainting or Vasovagal Syncope
Hepatitis or HIV
Medically diagnosed keloid formation
*
I consent to my jewelry change and acknowledge that it may cause some discomfort.
*
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 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
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