BOSTON TATTOO COMPANY PIERCING OVER 18 RELEASE FORM

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Boston Tattoo Company

Over 18 Piercing Release Form

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Today's Date* This field is required.
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Month
Day
Year
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Full Name:* This field is required.
Legal First Name
Legal Last Name
Preferred Name (“x” if same as Legal)
Pronouns (she/he/they etc)
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
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Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
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The Bahamas
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Christmas Island
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Colombia
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Cote d'Ivoire
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Cuba
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Denmark
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Gabon
The Gambia
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Iran
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Jordan
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North Korea
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
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Northern Mariana
Norway
Oman
Pakistan
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Peru
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Poland
Portugal
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Qatar
Republic of the Congo
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Rwanda
Saint Barthelemy
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Samoa
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South Ossetia
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eSwatini
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Other
Country
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Phone Number* This field is required.
Area Code
Phone Number
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E-mail* This field is required.
example@example.com
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Birth Date* This field is required.Please Select Your Birthdate (MM-DD-YYYY)
Date
Month
Day
Year
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Birth Date
Month
Day
Year
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Is Your Visit Today An Appointment?* This field is required.
Walk-In
Appointment
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Which Of Our Locations Are You Visiting Today?* This field is required.
Boston (Newbury Street)
Somerville (Davis Square)
Medford (Fellsway)
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How Did You Hear About Us?* This field is required.
Friend/Family Recommendation
Drive By / Walked By
Shop Social Media
Piercer Social Media
Web Search
Other
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In the last six months, have you received any Tattoos or Piercings?* This field is required.
Yes
No
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If selected "Yes” to the previous question, please provide an explanation of your recent Tattoos / Piercing.Ex. “I just had a 6hr session a few days ago”, “I had a triple helix done three months ago”, etc.
Please describe what work was performed
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Do You Feel Well Today?
YES
NO
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I do not have any medical conditions or skin conditions that may interfere with the application or healing of the piercing, and if I do I have spoken to my doctor about getting a tattoo or piercing for their guidance. I will verbally discuss with my piercer if any of the following apply to me, or if I am unsure of any conditions I have may affect my piercing or healing:* This field is required.I do not suffer from any of the following medical conditions, have a history of suffering from any of the following medical conditions, or take medication for any of the following conditions: - Diabetes - Epilepsy / Narcolepsy / Seizures - Fainting / Syncope / Vertigo - Hemophilia (excessive bleeding) - A heart condition (any) - Immunocompromising conditions (Lupus, Anemia, Long Covid, Cancer, etc.) - A history of skin diseases or skin lesions - Skin sensitivities, allergies, or adverse reactions to soaps, disinfectants, pigments, dyes, metals, etc. - Bloodborne diseases such as Hepatitis B, Hepatitis C, HIV/AIDS, or other pathogenic diseases - Currently take anti-coagulants (blood-thinners) that will affect clotting and healing - Currently take medication for immunodeficiencies - Am an organ- or bone marrow transplant recipient (or if I am, have taken the prescribed preventative regimen of antibiotics that is required by my physician in advance of this piercing - Pregnancy or Nursing (current) - Mental impairments that may affect my judgement
I DO NOT suffer from any of these condition(s)
I DO suffer from any of these condition(s)
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Have you had or been in close contact with anyone with COVID-19 in the past 14 days?* This field is required.
YESNO
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Have you had any of the following symptoms, in the past three days, that are not explained by allergies or non-infectious cause: Cough, Shortness of breath / difficulty breathing, Fever or chills, Muscle or body aches, Sore throat, Headache, Nausea or vomiting, Diarrhea, Runny or stuffy nose, Fatigue, Recent loss of taste or smell?Please verbally acknowledge any symptoms with your piercer for discussion
I have had one or more of these symptoms
I have NOT had any of these symptoms
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Have you been directed to quarantine or isolate in the last 14 days?* This field is required.
YESNO
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Have you been directed to quarantine or isolate in the last 14 days?
YESNO
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IF YOU HAVE ANSWERED YES to any of the following Covid-19 questions you may not be able to enter this building for the safety of the staff and other patrons.* This field is required.
I acknowledge
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CLIENT MAY BRING ONE TO TWO SUPPORT HUMANS MAX: to limit the number of person-to-person exposure, as well as not crowd the piercing room. Masks are recommended for your appointment but are not required. Please arrive to your appointment 5-10 minutes early to choose jewelry. Thank you for your patience and understanding, we look forward to seeing you soon!
I acknowledge
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I AM NOT under the influence of alcohol or drugs, Mental Duress, Coercion, or any factor that would inhibit my consent. I am voluntarily submitting to be pierced by the Piercer and The Boston Tattoo Company* This field is required.We care about your safety above all! If you are here with an unsafe person or in an unsafe situation please ask to speak to the piercer in private and we will make sure to get you the appropriate resources and consult privately with you to protect your safety. Our staff is here for you and wants to make sure you know you are safe here!
I consent
I do not consent
Other (I need to speak to the piercer)
Other
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I acknowledge that I have truthfully represented, with a photo ID to the Piercer and The Boston Tattoo Company, that I am at least (18) years of age or older, and that this information is true and correct. If I am not at least (18) years of age or older, I am to be accompanied by a birth parent or legal guardian, said birth parent or legal guardian acknowledges that they have truthfully represented with photo ID and supporting documentation that they are the birth parent or legal guardian of said minor.* This field is required.
I acknowledge
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I UNDERSTAND that a piercing is a permanent change to my appearance and that the skin cannot be returned to its original, un-pierced appearance, and how scarring forms is not responsibility of the piercer. Surface Anchor piercing is a more permanent type of piercing than a non-surface piercing because it “seats" in the skin under the epidermis, and parts of the jewelry can be changed but it can only be removed PERMANENTLY rather than just “taken out” (removal requires a piercer).* This field is required.
I understand
Other
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THE PIERCER AND THE BOSTON TATTOO COMPANY have given me instructions on the care of my piercing while it's healing; and I understand them and will follow them explicitly. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. If any corrective work to the piercing is needed due to my own negligence, I agree that the work will be done at my own expense.* This field is required.
I acknowledge
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How Many Piercing Would You Like Today?
Single Piercing
Multiple Piercings
Curated
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What Kind Of Jewelry Are You Be Pierced With?Ask your piercer if you are unsure of the terminology
Implant Grade Titanium/Steel/Niobium
14K Solid Gold with a Titanium Post
Glass
14K Solid Gold only
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Have you eaten and/or hydrated in the last four (4) hours?Please inform your piercer verbally! Skipping meals before piercings can increase the likelihood of dizziness/fainting.
I have had a full meal recently
I have snacked recently
I haven’t had anything to eat recently
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Please Describe The Type Of Piercing(s) Being Performed For You Today* This field is required.Ask your piercer if you are unsure of the terminology
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Where Will The Piercing Be Located On Your Body?* This field is required.
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Which Piercer Will You Be Working With Today?* This field is required.
Nicholas
Kris
Leslie
Lou
Matteo
Keith
Guest Piercer
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I AGREE that I have been fully informed of the inherent risks associated with getting a piercing. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to, infection, scarring, and allergic reactions (including materials involved in the piercing process such as latex gloves, soap, etc.) Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing process and I freely accept and expressly assume any and all risks that may arise from process.* This field is required.
I agree
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I ACKNOWLEDGE that both the Piercer and The Boston Tattoo Company have given me the full opportunity to ask any and all questions about the piercing & piercing process and all of my questions have been answered to my total satisfaction.* This field is required.
I acknowledge
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I AGREE to reimburse each of the Piercers and The Boston Tattoo Company for any attorneys' fees and costs incurred in any legal action I bring against either the Piercer or The Boston Tattoo Company and in which either the Piercer or The Boston Tattoo Company is the prevailing party. I agree that the courts of Massachusetts shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.* This field is required.
I agree
Other
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I AGREE TO WAIVE AND RELEASE to the fullest extent permitted by Massachusetts Law each of the artists, owners, corporate officers, employees, apprentices, assignees, independent contractors and successors, and The Boston Tattoo Company, d/b/a Type A Design, LLC, from any and all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assignees may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my piercing, whether caused by the negligence or fault of either the piercer or The Boston Tattoo Company.* This field is required.
I agree
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Please take a snapshot of your photo ID and/or birth certificate by clicking the button below: (scroll down if “Take Photo” button is not in frame)* This field is required.Please Make Sure The ID Is Fit Within The Screen - Thank You! Scroll down if you do not see “Take Photo” in blue
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I have reviewed, understood, and agreed to the policies and requirements of The Boston Tattoo Company, and hereby give my consent to The Boston Tattoo Company to perform the piercings on my person. I have received and agree to follow all aftercare instructions.* This field is required.Please sign your name with a finger or stylus
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