Piercing Release Form

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Let us do this part

Today's Date:

Mon Nov 18 2024 05:57

Practitioner:*

Body Piercing Location (on the body):*

Please read and answer

Symptoms*

I confirm that I am not presenting ANY of these symptoms of COVID-19 including, but not limited to:
Dry cough
Runny nose
Sore throat
Shortness of breath/wheezing
Loss of taste or smell
Temperature exceeding 100 degrees F
I confirm that I HAVE NOT been in contact with anyone exhibiting the aforementioned symptoms, or anyone who has been diagnosed with COVID-19 within the past 14 days.

How did you hear about us?

Photography*

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.

Have you Eaten?*

Have you eaten in the past 4hrs? It's a good idea to eat before hand to increase your blood sugar levels.

Bloodbourne Pathogens*

Do you currently have, in a communicable stage, an infectious or contagious disease, parasitic infestation, weeping lesions or weeping dermatitis? (It's OK if you do, we just need to know for the safety of our staff.)

Accutane*

I affirm that I AM NOT currently using or HAVE NOT used Accutane within the last year as this can have impacts on the ability to heal any and all piercings.

Topical Numbing Agents*

I affirm that I AM NOT currently using any topical numbing agents on the area that is being pierced.

Risks*

I understand that by getting a piercing. I am creating an open wound on my body. I understand that any open wound can potentially become infected, especially if not cared for properly or if it's neglected. I understand that a foreign object in my body known and unknown, can lead to injury, including but not limited to infection, scarring, keloiding and allergic reactions. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept all risks that may arise from the piercing.

Release*

TO WAIVE AND RELEASE: Being of sound mind and body, I hereby release ANY & ALL persons representing Neon Dragon & Body Piercing by JayR from any and all responsibilities. I accept any and all responsibility for ANY consequences which may stem from my decision to get a piercing. I understand that there are risks associated with getting a piercing. I agree to be solely responsible for any and all financial loss incurred, including but not limited to medical bills, loss of work, permanent disability, pain and suffering and any others not covered here. I voluntarily release Neon Dragon Tattoo, Body Piercing by JayR, its owners, operators, employees, agents or anyone associated with these establishments of any responsibilities resulting from my voluntary request to receive a piercing.

Questions*

I have been given the opportunity to ask any and all questions about the piercing procedure and they have been answered to my total satisfaction.

Aftercare*

I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. I take any and all responsibility for the aftercare of my piercing.

Under the Influence*

I am not currently under the influence of any drugs, alcohol, or any substances that affect my judgement.

Medical Conditions*

I confirm that I am not pregnant or nursing.

I confirm that I have notified the staff of any medical conditions such as diabetes, epilepsy, hemophilia, HIV, AIDS, Hepatitis, or heart conditions that could impact the procedure or healing of a piercing. I am also not a recipient of an organ or bone marrow transplant; if I were, I would have adhered to the prescribed antibiotic regimen as recommended by my doctor before undergoing any invasive procedure, including a piercing or stretch. I am not on blood thinners; If I were, I have confirmed from my doctor that it is safe to proceed with any piercing or stretching.

Treatment / Cure / Remedy*

I acknowledge that piercing procedures performed at Neon Dragon are not intended to treat or diagnose any conditions or ailment and are performed solely for the purpose of adornment. Further more, I acknowledge that no member of the Neon Dragon staff is performing as a medical professional, and have given no implications otherwise. At no point in time have I been led to believe that this piercing procedure is a treatment, cure or remedy for any medical conditions. Being of sound mind and body, I hereby release ANY & ALL persons representing Neon Dragon & Body Piercing by JayR from any and all responsibilities associated with any and all piercing procedures.

This Document*

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.

I am aware*

I understand that no representative of this establishment is a medical professional and all information given is based on best practices, general industry knowledge, general wound healing and by no means is meant to constitute medical advice.

I understand it is MY RESPONSIBILITY to seek medical attention and medical advice if I feel it is necessary. It is NOT the responsibility of the Neon Dragon Piercing Staff or BodyPiercingby JayR, LLC to suggest medical attention. I TAKE ALL RESPONSIBILITY FOR RECEIVING AND THE HEALING OF THIS PIERCING.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

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.

Legal Name:*

Pronoun:

Chosen name:

Address:

Postcode:

Date of birth:*

If you are under 18 your parent/guardian will be required

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.