This is a sample consent form (waiver and release form) for body piercing. Please consult with local counsel before distributing to clients as laws may vary by state and local jurisdictions.
Name:___________________________________________
Appointment Date:_________________________________
Birth Date:________________________________________
Driver’s ID:________________________________________
Address:__________________________________________
Phone #:__________________________________________
E-mail:___________________________________________
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a body piercing or microdermal (single point piercing) and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows:
- I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take medication which thins the blood. I have informed my Piercer of any condition such as diabetes that might hamper the healing of the piercing.
- If I suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advised of any procedures necessary to promote the satisfactory healing of my piercing.
- I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds, infections, rashes, or lesions at the site of the piercing.
- I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.
- I have trustfully represented to the Piercer that I am over the age of eighteen (18) years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.
- I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to restore the skin involved in this piercing to is pre-piercing condition.
- I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and agree to follow all of them while my piercing is healing.
- I understand that a microdermal (single point piercing) consists of a pierced point of entry but not a point of exit. Specially designed jewelry is inserted into the pierced area and sits below the skin where it becomes anchored.
- I understand I will be pierced using appropriate instruments and sterilization.
- I understand that __________________reserves all rights to use any photos of my piercing or tattoo taken in ___________________.
Therefore, I request the Piercer to pierce my ________________ . I understand this type of piercing usually takes ________________ or longer to heal. I hereby release and forever discharge and hold harmless ________________, the Piercer and all affiliates, Owners, Managers, and Employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing, to the fullest extent allowed by the law.
By signing below, I, ________________________ , or their legal guardian, agree that I have read the Body Piercing Release form provided by ________________ and agree to its terms.
Client Signature:__________________________________________Date:____________________
