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Trilllogy Tattoo & Piercing Consent Form

Let us do this part

Today's Date:

Mon Nov 25 2024 06:57

Practitioner:*

Area of the body:*

Please read and answer

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?

Eaten*

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

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).

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.

Medical Conditions*

I affirm that I do not have diabetes, epilepsy, hemophilia, nor do I have a heart condition or take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure or healing of the piercing. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as piercing. I am not pregnant or nursing.

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 Ca in USA 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 by the artist and give full consent in advance to their reproduction in print or electronic form.

I fully understand that I, or anyone else cannot take pictures or video while the procedure is in place. If found doing so, I understand that I or anyone else will be asked to leave immediately.

Vaccine Card*

We do not require to see your Vax card. We feel it is none of our business to know your personal decisions to be vaccinated.

Although, if you feel more comfortable letting us know and would like to show proof, you can take a picture of the card along with your ID.

If you feel you want to decline for that proof, Please know that you have/must follow all CDC recommendations in our facility.

Being of sound, mind and body, I hereby release any and all persons representing Trilllogy Tattoo / Piercing from ALL responsibility.

I accept any and all responsibility for any consequences that might stem from my decision to have any services or any related work done by Trilllogy Tattoo/Piercing.
I agree to not sue anyone in connection with any and all damages, claims, judgments, rights and causes of action arising from my decision to have services whether or not caused by any negligence of anyone.
I agree for myself and my heirs, assigns, and legal representatives to hold all harmless from Trilllogy Tattoo/Piercing damages, actions, causes of actions, claims, judgments, cost of litigation, attorney fees and any other costs and expenses which arise from my decision to have services/ and or related work done by anyone representing Trilllogy Tattoo/Piercing
I agree to pay for all damages and injuries to any and all persons and property belonging to Trilllogy Tattoo/Piercing, and any persons to whom may become liable contractually or by operation of law caused by, or resulting from any decision to have any services/ and or related work done by anyone representing Trilllogy Tattoo/Piercing.
I agree to leave the premises of/and or any other establishment where Trilllogy Tattoo/Piercing is engaged in business, promptly upon request, for any reason whatsoever, by any agent or employee at any time.
I agree that these waivers also pertain to and are designed to protect and protect all establishments where Trilllogy Tattoo/Piercing conducts business.
I agree to have ALL pertinent documents copied and given to Trilllogy Tattoo/Piercing for their records.
I agree to follow aftercare guidelines that are provided to me verbally and/or written instructions until healing is complete.
I fully understand that any/all aftercare measures, not approved by Trilllogy Tattoo/Piercing, that I decide to follow on my own without consulting Trilllogy Tattoo/Piercing, is at my own risk.
I am in full understanding of the possible complications such as, but not limited to, infection, allergic reaction, migration and/ or rejection.
I am in full understanding that the services being performed, I am making a permanent change to my body and no claims have been made regarding the ability to undo any changes made.
I am in full understanding that misrepresentation, falsifying of any information provided by me is a crime and I can be subject to prosecution.
I further state and certify that I am an adult over the age of 18, not intoxicated or under the influence of any drugs or alcohol, illegal substances, narcotics whether legal or illegal, and make these and all statements fully and completely of free will and sound mind.
I hereby grant Trilllogy Tattoo/Piercing and any licensees, agents, and assignee's thereof (collectively) the perpetual, irrevocable, global and unrestricted right to use, reproduce, publish and copyright my picture(s), likeness, of/and voice along with video in/or any media for publicity, art, advertising, trade, or for any other lawful purpose.
I understand that my image may be substantially edited, altered, or modified. I hereby waive any right to inspect or approve my image(s). in any media.I grant the right to market and sell copies of my image(s)..
I also waive any right to royalties or other compensation related to my image(s).I release any and all legal representatives and assigns thereof from any claims in connection with the use of my image(s). I intend for this agreement to bind all of my heirs, assignee's, personal representatives, and members of my family.
I hereby release Trilllogy Tattoo/Piercing from all manners of liabilities, claims, actions, and demands, in law or in equity, which I or my heirs might now or in the future, of now or after, by any reason of complying with my request to have services by Trilllogy Tattoo/Piercing.

TOOTH GEMS:
I understand that Trilllogy Tattoo/Piercing and its agents make no claims, warranties, or guarantees as to the safety of any materials including but not limited to the jewelry itself, glues or any other products used in the application of the tooth gem.
I understand that having this service is temporary.
I understand that if my Tooth Jewelry falls out for any reason except mistreatment or failure to properly follow aftercare guidelines during the two weeks following the procedure, it will be replaced at no charge. After two weeks there is no guarantee, or warranty of replacement. If I wish to have another tooth jewelry installed, I will bear the cost of the service and jewelry myself.
If my teeth or any other body part is harmed in any way from having this service done, I myself will be responsible for any charges that will be made to me for the repairs by a professional. (I.e. chipping, biting, etc.)
If in the event I no longer wish to have my tooth jewelry, I myself will be responsible for all charges that will be made to me by a dental professional in the removal of my tooth jewelry.
ALL services , procedures, jewelry sales and tooth gem installations are final.
No refunds and No exchanges of any kind.

****For the current COVID-19 update:
Please understand that in order to keep up with the current Covid19 Health orders: ***
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
*I further acknowledge that Trilllogy Tattoo/Piercing has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
*I further acknowledge that Trilllogy Tattoo/Piercing can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other salon clients and their families.
*I voluntarily seek services provided by Trilllogy Tattoo/Piercing and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the UK in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
* I fully understand that Trilllogy Tattoo/Piercing does not require to see my vaccination card, and if I decide to not provide proof and any/all situations that can stem from it, I am fully liable.

I hereby release and agree to hold Trilllogy Tattoo/Piercing harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Trilllogy Tattoo/Piercing or that may otherwise arise in any way in connection with any services received from Trilllogy Tattoo/Piercing

I understand that this release discharges Trilllogy Tattoo/Piercing from any liability or claim that I, my heirs, or any personal representatives may have against Trilllogy Tattoo/Piercing with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Trilllogy Tattoo/Piercing.

I fully understand there if any of my property is lost,misplaced or forgotten, Trilllogy Tattoo is not responsible in any way shape for form.

This liability waiver and release extends to the establishment, together with all owners, partners, and employees.

I have read and understand all sections of this contract to its entirety.

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.

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.