The Golden Pearl Piercing-Waiver (2021)

The Golden Pearl

7C-77 Lakeshore Rd West. Oakville, Ontario, L6K1C9 (289)-837-4496
CONSENT TO APPLICATION OF PIERCING

PLEASE FILL ALL THE INFORMATION LISTED BELOW AFTER READING TO SHOW THAT YOU UNDERSTAND EACH PROVISION. FEEL FREE TO ASK ANY QUESTIONS REGARDING THIS WAIVER.
PIERCERS NAME
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH*

MonthDayYear
Date
EMERGENCY CONTACT NAME*

First NameLast Name
EMERGENCY CONTACT PHONE NUMBER*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about The Golden Pearl?
Answer YES or NO to the following questions
1. Do you have a fever and /or chills*
Answer YES or NO
2. Do you have a cough or barking cough (croup)?*
Answer YES or NO
3. Do you have shortness of breath?*
Answer YES or NO
4. Do you have a sore throat?*
Answer YES or NO
5. Do you have difficulty swallowing?*
Answer YES or NO
6. Do you have a decrease or loss of smell or taste?*
Answer YES or NO
7. Do you have Pink Eye?*
Answer YES or NO
8. Do you have a runny or stuffy/congested nose?*
Answer YES or NO
9. Do you have a headache?*
Answer YES or NO
10. Do you have digestive issues like nausea/vomiting, diarrhea, stomach pain?*
Answer YES or NO
11. Do you have muscle aches?*
Answer YES or NO
12. Do you have extreme tiredness?*
Answer YES or NO
13. Do you have issues with falling down often?*
Answer YES or NO
14. Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (staying at home)?*
Answer YES or NO
15. In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Answer YES or NO
16. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?*
Answer YES or NO
17. In the last 14 days, have you travelled outside of Canada?*
Answer YES or NO
18. Are you pregnant?*
Answer YES or NO
19. Are you breastfeeding?*
Answer YES or NO
20. Are you under the influence of drugs or alcohol?*
Answer YES or NO
21. Do you have epilepsy or hemophilia?*
Answer YES or NO
22. Do you suffer from any heart conditions or take medication which thins the blood?*
21. Do you have any allergies? If YES, please list allergies (ie. metals, latex, soaps, medications etc?:*
23. I fully understand that complications may occur, such as infection/allergic reactions.*
Answer YES or NO
24. Do you have any medical conditions or bleeding disorders? (example: Diabetes) If YES, please list:*
Answer YES or NO
25. Do you have HIV, AIDS, Hepatitis or any other communicable disease?*
Answer YES or NO
26. Do you suffer from medical or skin conditions such as, but not limited to: Keloid or Hypertrophic scarring, psoriasis, allergies, open wounds, rashes, or lesions at the site of the piercing?*
Answer YES or NO
27. I acknowledge it is not reasonably possible for the piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing*
Answer YES or NO
28. Do you have any physical, mental, medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time?*
Answer YES or NO
29. I acknowledge that obtaining this piercing is my choice alone and will result in permanent change to my appearance, and that no representation has been made to me as the ability to restore the skin involved in this piercing to be pre-piercing condition.*
Answer YES or NO
30. I agree to follow the aftercare instructions given to me.*
Answer YES or NO
31. I understand I will be pierced using appropriate instruments and sterilization.*
Answer YES or NO
32. Have you been vaccinated against COVID-19? (not required for a piercing)
Answer YES or NO
33. Do you understand that The Golden Pearl or any of the piercers at The Golden Pearl will not be liable in the event that the COVID-19 vaccine causes a reaction to the body?
Answer Yes or No
34. I have answered all of the above questions truthfully.*
Answer YES or NO
I WAIVE AND RELEASE to the fullest extent permitted by law each of the piercers at The Golden Pearl from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury otherwise, including or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my piercing, whether caused by the negligence or fault of either the piercer or The Golden Pearl Tattoo Studio, or otherwise.

I acknowledge that by signing this waiver, I have been given the full opportunity to ask any questions which I might have obtaining a piercing from The Golden Pearl. I agree with the terms and conditions and that my questions have been answered to my satisfaction.
Signature*

Clear
Todays Date*

MonthDayYear
Date
Proof of Identification (i.e. Drivers license, bring with you to your appointment):*

Cancelof
THIS SECTION IS FOR CLIENTS UNDER THE AGE OF 15
Name of parent approving tattoo for minor:

First NameLast Name
Parent Date of birth:

MonthDayYear
Date
Proof of Identification (i.e. Drivers license, bring with you to appointment):

Cancelof
I give the artist permission to perform a tattoo procedure on (minor's name) and take full responsibility from any issues that may arise.
Answer Yes or No
Parent Signature:

Clear
Minors Signature:

Clear
DON’T FORGET TO CHECK INTO THE GOLDEN PEARL TATTOO ON FACEBOOK

FOLLOW US ON INSTAGRAM!!! @THEGOLDENPEARLTATTOO
Should be Empty:

The Golden Pearl

CONSENT TO APPLICATION OF PIERCING

THIS SECTION IS FOR CLIENTS UNDER THE AGE OF 15