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Jewelry Change/NPCU

Let us do this part
Today's Date:
Fri Aug 15 2025 10:32
Practitioner:*
Piercing Name:*
Artist signature:*


Please read and answer
Y
N
Are you pregnant or nursing?*
Details:
 
Y
N
Do you have Flu like symptoms?*
IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.
 
How did you hear about us?
 
Y
N
Eaten*
Have you eaten in the past 4hrs? It's a good idea to before hand to increase your blood sugar levels.
Y
N
Bloodbourne Pathogens*
Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety). If you feel comfortable enough to do so, please notify staff. Thank you!
Details:
 
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 given me 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.
Y
N
Medical Conditions*
If you have diabetes, epilepsy, hemophilia, a heart condition, or take blood thinning medication. If you have any medical or skin condition that may interfere with the procedure or healing of the piercing. If you are the recipient of an organ or bone marrow transplant, and have or have not taken the prescribed preventive regime of antibiotics that is required by your doctor in advance of any invasive procedure such as a piercing. If you are pregnant or nursing. If yes, please elaborate. Also alert your artist. Thank you!
Details:
 
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.
Y
N
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.
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 [STATE] in [COUNTRY] 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.
Y
N
Physical Ailments*
Do you have any physical conditions that will make piercing you difficult or impossible? (Unable to sit, lay down, etc.)
Details:
 
Swimming/Submerging*
I acknowledge that I will not submerge my piercing into any bodies of water for at least two weeks (i.e., pools, lakes, bathtubs, hot tubs, waterparks, etc.) Showering is okay!
Extra Minor Policy*
Any child who has NOT been pierced in our studio and is under the age of 10 will require an adult to supervise them if their sibling and/or parent is being pierced or getting jewelry changed. This is for safety and to provide a great experience for the person getting pierced.
PLEASE NOTE: Paperwork and ID is required for every visit with us. Please come prepared!
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.
Legal Name:*
Pronoun:
Chosen name:
Address:
Postcode:
Date of birth:*
Phone #:*
Email:*
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Signature:*


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