Permanent Jewelry Consent Form

Full Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

Phone Number

Please enter a valid phone number.

Do you have any chronic medical conditions?

YesNo

If so, please explain.

Skip if previous answer is No.

Do you have any Allergies?

YesNo

If so, please explain.

Skip if previous answer is No.

Are there any pre-existing skin conditions or scarring in the area where the welding will take place?

YesNo

Do you have any sensitivity or allergy to metals?

YesNo

Do you have any Photosensitivity?

YesNo

Do you have Epilepsy or Parkinson's disease?

YesNo

Do you have or have you had Cancer in the last 12 months?

YesNo

If yes, are you currently under Chemotherapy or Radiation?

YesNo

Are you currently (or possibly may be) Pregnant?

YesNo

Do you have a pacemaker?

YesNo

Understanding of Risks and Procedure:

I have voluntarily elected to undergo this appointment after the nature and purpose has been explained to me, along with the risks and hazards involved by Hoosier Jewelry. Avoid if possible, exposure of jewelry to chemicals, household cleaning products, chlorine, swimming pools, or hot tubs. These different chemicals, can harm,discolor or affect the integrity of materials over time.

Consent and Release:

I voluntarily and willingly consent to the permanent jewelry procedure and assume any risks associated with it. By signing this form, I release Hoosier Jewelry, its practitioners, employees, and affiliates from any liability for complications, injuries, or damages resulting from the procedure. I agree to provide accurate and complete information about your health history, including anymedical conditions, allergies, or medications that may affect your ability to undergo the weldingprocess. I also acknowledge that any injury or harm that results from the welding process is solely my responsibility.

Age Verification:

I confirm that I am at least 18 years of age, or if I am a minor, I have obtained the consent of my parent or legal guardian for this procedure.

Photo Release:

I give permission for photographs or images of the procedure and the jewelry placement to be taken for website display, social media marketing, documentation, and educational purposes.

Signature:

I have read and understood this Permanent Jewelry Consent Form, and I sign it of my own free will.

Date

Please verify that you are human*

Signature

Permanent Jewelry Consent Form

Client Information

Health Information