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Piercing Release

Let us do this part
Today's Date:
Mon Nov 18 2024 12:32
Practitioner:*
What piercing(s) are we doing? Example: lobe, daith, tragus, nostril:*
Terminology: Monarch Fine Jewelry + Professional Piercing is referenced here also as the "Piercing Studio" or "Studio"; the individual performing the service(s) as the "Piercer" or "Practitioner"; the owner, employees, piercers, and guest artists as "Staff".

If any information is not accurate or the picture is not in focus, you may have to do the form again.

You must attach your unexpired, government-issued photo ID, such as a state-issued driver's license.

** FOR MINORS --

Fill the client information with the minor's information. A dropdown will appear for parent/guardian information once their age is selected. When adding images of your IDs, include the birth certificate and/or other guardianship paperwork.

A button will show below your first uploaded image to "+ Another Photo" so that you may upload each necessary document.
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.
Please read and answer
Y
N
Choice*
Is receiving this piercing my choice alone? (In the case of a minor, is the minor making this choice themselves and not being coerced in ANY way?)
Y
N
Eaten *
Have you eaten in the past 4 hours? (If answering for a minor, respond as the minor in question)
Y
N
Fainting*
Are you prone to fainting ("passing out")? (If answering for a minor, respond as the minor in question)
Y
N
Pregnancy*
Are you pregnant or nursing (breastfeeding)? Do you reasonably anticipate you will become pregnant before the healing of this piercing is complete? (If answering for a minor, respond as the minor in question)
Y
N
Blood Thinning*
Have you consumed alcohol, ibuprofen, or any other blood-thinning substances/drugs/medications within the last 24 hours? (Answering YES does not inherently prevent someone from receiving the service, so please answer HONESTLY.) (If answering for a minor, respond as the minor in question)

If YES, please include ALL THREE OF THE FOLLOWING:
(1) the substance consumed (alcohol, ibuprofen, etc.);
(2) how much was consumed (mg, amount of drink, etc.);
and (3) how long ago you consumed the substance.
Details:
 
Y
N
Allergies*
To the best of your knowledge, are you allergic to iodine, rubbing alcohol, nitrile, or any other item that may be used for the procedure? (If answering for a minor, respond as the minor in question)

If YES, what?
Details:
 
Y
N
Skin Condition(s)*
Do you have any skin condition(s) that could affect the piercing or its healing? (Answering yes does not inherently stop you from receiving a piercing, so please answer honestly!) (If answering for a minor, respond as the minor in question)

If YES, what? Is the area we are piercing today prone to experiencing this condition? Is the area experiencing this condition currently?
Details:
 
Y
N
Medical Condition(s)*
Do you have diabetes, epilepsy, hemophilia, any heart condition(s), or other condition(s) that would make receiving or healing the piercing difficult? (Answering yes does not inherently stop you from receiving a piercing, so please answer honestly!)

If YES, you are welcome to leave more details if you would like so that we may better serve you.
Details:
 
General Health*
(If answering for a minor, respond as the minor in question)

To the best of my knowledge, I do not have any illness or medical/skin condition(s) that may interfere with the procedure or healing of the piercing, except any that I have described above.

I am not the recipient of an organ or bone marrow transplant(s) or, if I am, I have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as piercing.

Neither I nor any individuals I have brought with me have tested positive for COVID-19 within the past 21 days.

Neither I nor any individuals with me have come into contact with someone who was exhibiting symptoms of COVID-19 within the past 21 days.

Neither I nor individuals with me are currently exhibiting ANY of the following symptoms:

fever or chills, cough, new shortness of breath or difficulty breathing, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or new confusion.
Consent & Duress*
To the best of my knowledge, I do not have any mental impairment or disability which may affect my decision or ability to consent at this time.

I affirm that I (nor the minor, if applicable) am not currently under the influence of any alcohol or drugs.

I agree that receiving the service(s) is my (or the minor's) choice alone, and no one else is pressuring or coercing me (or the minor).
Age*
I have trustfully represented to the Piercing Studio that I am either at least 18 years of age or that I am an emancipated minor.

If I am signing/consenting for a minor, I agree I am the parent, legal guardian, or legal custodian of the individual being pierced. I, the undersigned, am fully aware that to falsify legal standing as to parentage or being the legal guardian or legal custodian is a Class C misdemeanor; and, Pursuant to ยง 40-35-111, a Class C misdemeanor means imprisonment for a period of no greater than thirty (30) days or a fine not to exceed fifty dollars ($50.00), or both.
Aftercare*
The Studio most frequently gives detailed verbal aftercare before you leave. You may also contact The Studio with questions if you have them after you leave. Additionally, you may visit https://monarchpiercing.com/aftercare or https://safepiercing.org/aftercare/ at any time.

Aftercare will vary with each piercing but also focuses on what NOT to do -- avoid introducing the piercing to irritants or foreign bodies, including from touching, twisting, submerging, or removing jewelry/the piercing while healing. Soaps and most chemicals should be avoided within the piercing site itself.

I affirm this means I have access to aftercare instructions on the care of the piercing while healing, and I that understand them and will follow them.

I acknowledge that it is possible that any piercing can become problematic, particularly if I do not follow the instructions.
Jewelry Selection*
If I believe the jewelry is not an appropriate size for any reason, I will let the Piercer/Piercing Studio know right away and take immediate action to correct it.

I understand that the jewelry for the piercing(s) is at least in part chosen by the Piercer, and the jewelry the Piercer has chosen for me is what they feel is the most appropriate size and style for the area being pierced and for any reasonably anticipated inflammation.

I understand The Piercer and the Piercing Studio are not responsible for any incident or changes in my body that may cause this jewelry to no longer fit properly in any way.

I understand that jewelry is warranted to be free from defects in materials or workmanship for life as determined by the manufacturer, and that Monarch Fine Jewelry + Professional Piercing has no control over what a jeweler determines is coverable.
Permanent Change & Risks*
I understand that risks of getting a piercing, known and unknown, can lead to injury, which include, but are not limited to, infection, scarring, keloid development, and allergic reactions.

I acknowledge that the piercing will result in a permanent change to appearance and that skin may not be restored to its pre-piercing condition, even after its potential removal, regardless of any reaction, condition, etc.

I acknowledge the Piercer cannot determine whether any individual may have an allergic reaction to the jewelry in this piercing, and I further acknowledge that such a reaction is possible.

I understand that while the piercing is being performed using sterile materials, there is always a possibility of infection. I cannot hold the Piercer or the Piercing Studio responsible for an infection that develops as a result of care or lack of care during healing. If I believe the piercing is infected, I will seek immediate treatment from a doctor.

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, known or unknown, that may arise from piercing.
Contact*
I give my explicit consent granting Monarch Fine Jewelry + Professional Piercing, the Piercer, the Piercing Studio, and its employees to contact me through email and phone, including SMS and MMS messaging, regarding services, appointments, jewelry, and other aspects pertaining to the business. Monarch will never sell your information or use your information to send marketing emails, only those pertaining to your services and jewelry.

I understand the Piercing Studio does not have control over Square, Squarespace, or other companies/tools used by the Piercing Studio and the way in which they use data provided. If I wish to revoke the ability to be contacted, I must let the Piercing Studio know in writing. I understand revoking Monarch's ability to contact me will not inherently remove what contact is done through the services of Square, Squarespace, or other companies/tools the Piercing Studio uses.
Photography
I grant the Piercing Studio permission to take my (and/or the minor's) likeness in any photograph(s) in any way they choose. I release all rights to any photograph(s) taken of me (and/or the minor) and the piercing, and I give consent in advance to reproduction in print or electronic form, including, but not limited to, social media. I will not make monetary or other claim(s) against the Piercing Studio, Piercer, or affiliates for the use of the photograph(s).
Payment*
Payment will be made in full to the Studio via cash, approved payment card, or by other payment method determined by the Studio. Unpaid or overdue invoices may result in collection of payment, including using the card(s) on file. Late cancellation and/or "no-shows" may result in a fee, the collection of payment for which may include using the card(s) on file, dependent on the service(s) booked. You agree to pay any and all service fees, late cancellation/no-show fees, and/or prices of the jewelry used in the service.

I agree unconditionally that no refunds will be provided for the services performed by or for the jewelry purchased from the Studio.
Legal Document*
The Piercer, the Piercing Studio, and its employees have given me the full opportunity to ask any and all questions about the piercing procedure, and they have been answered to my total satisfaction.

I acknowledge that I have been given adequate opportunity to read and understand this document, including the provisions below. I agree to all terms in this document.

I understand that I am signing a legal contract.
In addition to the agreed terms above, by signing, you additionally agree to the following:

I agree to follow all Monarch Fine Jewelry + Professional Piercing guidelines, terms, conditions, and policies, including those not outlined here. I understand that for more terms and guidelines can be found on The Studio's website, and I had to agree at https://monarchpiercing.com/terms before booking.

I understand that all guidelines, terms, conditions, and policies can be changed at any time but are always available to view at https://monarchpiercing.com/terms.


I, the individual receiving services, and anyone claiming on my and/or the individual receiving the service(s)'s behalf, expressly release, waive, and forever discharge to the fullest extent permitted by law each Piercer, the Piercing Studio, its affiliates, successors and assigns, employees, representatives, partners, and anyone claiming through them from all liability whatsoever in their individual and/or corporate capacities, for any and all claims or causes of action that I, my estate, heirs, executors, or assigns may have, for personal injury, illness, disability, damage, loss, or otherwise, including any direct and/or consequential damages which result, arise, or relate, whether caused by the negligence or fault of the Piercer, the Piercing Studio, its affiliates, successors and assigns, employees, representatives, partners, and anyone claiming through them, or otherwise.

I understand that Monarch Fine Jewelry + Professional Piercing has put in place preventative measures to reduce the spread of COVID-19, but that nonetheless, infection can occur anywhere. I understand no business can completely prevent someone from becoming infected. I understand being in any business or public place can potentially increase my risk of contracting COVID-19. I am aware of the highly contagious nature of COVID-19 and the risk that I may be exposed to or contract COVID-19 by entering the Piercing Studio or interacting with its employees or the Piercer.

I acknowledge that I am voluntarily entering the Piercing Studio with knowledge of the danger involved. I hereby agree to accept and assume all risks of personal injury, illness, disability, or death, including that related to COVID-19, arising from my being on the Premises or engaging in the Activity, whether caused by negligence of the Piercing Studio, its employees or affiliates, the Piercer, or otherwise.

I agree to reimburse each of the Piercer(s), the Piercing Studio, and the Studio employees for any attorney's fees and costs incurred in any legal action I and/or the person receiving services bring against the Piercer, the Piercing Studio, its affiliates, successors, employees, representatives, and anyone claiming through them in which the Piercer, the Piercing Studio, its affiliates, successors, employees, representatives, and anyone claiming through them is the prevailing party. I agree that the court(s) 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.
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:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #: