←

Piercings by Bee, LLC

Let us do this part

Today's Date:

Fri Nov 1 2024 10:23

Practitioner:*

Procedure to be Performed:

Consent and Release Form

Please read and answer

How did you hear about us?

Eaten*

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

Details:

Bloodbourne Pathogens*

Do you have any bloodborne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety and to discuss how it will affect healing).

Details:

Medical Conditions*

Do you have diabetes, epilepsy, hemophilia, or do you have a heart condition or take blood thinning medication, or have any other medical or skin condition? (It’s okay if you do, as long as your doctor has said it’s okay.)

Details:

Pregnancy*

Are you or have you been pregnant or nursing within the past six months?

Risks*

That I have been fully informed of the risks, associated with getting a piercing. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring and 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 piercing.

Release*

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Piercing Studio 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 or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise.

Questions*

That both the Artist and the Piercing Studio have given me the full opportunity to ask any and all questions about the piercing procedure and the they have been answered to my total satisfaction.

Aftercare*

I affirm that I have been or will be given instructions on the care of my piercing while it’s healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions.

Duress*

I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.

Permanent change*

I acknowledge that the piercing will result in a permanent change to my appearance and that my skin may not be restored to its pre-piercing condition even after its removal.

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.

Attorney Fees*

I agree to reimburse each of the Artist and the Piercing Studio for any attorneys. fees and costs incurred in any legal action I bring against either the Artist or the Piercing Studio and in which either the Artist or the Piercing Studio is the prevailing party. I agree that the that the courts of Kern County 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.

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.

COVID-19*

I affirm that I am aware of COVID-19 and its symptoms. I have not been out of the country, nor have I been possibly exposed to COVID-19 to my knowledge. I have been practicing social distancing for at least the past 14 days and have shown no symptoms of the virus. I do not have any other illnesses that could be contracted by others during my piercing.

Refunds*

I affirm that I understand that no refunds will be issued once a service is performed and that I am fully responsible for my piercing and jewelry. I understand that jewelry may not be returned once it has been in my possession. I understand the limitations of the warranty of my jewelry and that I am responsible for damages other than manufacturing errors. I understand that removal of my jewelry resulting in loss of the piercing is my responsibility.

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:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:

Photo ID*

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