Body Piercing Consent & Release Form printable pdf download

COLORFAST STUDIOS 2

BODY PIERCING CONSENT & RELEASE

Name:_____________________________________

Address:_________________________________________________________________

Date of Birth:____________________________ Home Phone: _____________________

opportunity to

I, <<First_Name>> <<Last_Name>>, acknowledge by signing this agreement that I have been given the full

ask any and all questions which I might have about the obtaining of a body piercing and that all of my questions have

been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth

below and I agree as follows:

___ I acknowledge I am over the age of 18 and that I have truthfully represented to my Piercer that the obtaining of this

body piercing is by my choice alone. I consent to the body piercing and any actions necessary to perform the

procedure.

___ I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take

medication which thins the blood. I have informed my Piercer of any condition such as diabetes that might hamper

healing of the piercing.

___If I suffer from hepatitis or any other communicable disease, I have informed the Piercer of this fact and I have been

advised of any procedures necessary to promote the satisfactory healing of my piercing.

___ I am not under the influence of drugs or alcohol. To the best of my knowledge I do not have any physical, mental,

or medical impairments or disability, which might affect my well being as a direct or indirect result of my decision to have

any piercing related work done at this time.

___ I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid), eczema, psoriasis,

freckles, moles or sunburn in the area to be pierced that may interfere with said piercing.

___I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. 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 and further acknowledge that such a reaction is possible.

___ I understand I will be pierced using sterilized instruments and appropriate techniques. I acknowledge infection is

always possible as a result of obtaining a piercing. I have received aftercare instructions and I agree to follow all of them

while my piercing is healing.

___I acknowledge that this piercing is a permanent change to my appearance and that no representations have been

made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition.

___Therefore, I request the Piercer to pierce my ___________________ . I understand this type of piercing usually

takes __________________________or longer to heal. I agree for myself, my heirs, assigns and legal representatives

to release and forever discharge and hold harmless COLORFAST STUDIOS 2, the Piercer and all employees from any

and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and

conduct used in my piercing.

___ I agree that these waivers also pertain to and are designed to protect any and all establishments where

COLORFAST STUDIOS 2 conducts business.

Customer Signature: ______________________ Date: _____________ Age: _____

OCCUPATION _________________________________RACE ____________________ SEX: _______

EMERGENCY CONTACT

PHYSICIAN

Name & Phone Number_______________________Name & Phone Number ______________________

**************************************DO NOT WRITE BELOW THIS LINE****************************************

PIERCER NAME ________________________________PRICE $ __________CASH / CREDIT

TYPE OF JEWELRY ________________________

Body Piercing Consent & Release Form

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