Loading...

Piercings by Jenn LLC dba Curated Private Studio Waiver



Piercing Consent Release Forms

PLEASE READ AND CHECK THE BOXES BELOW, THAT YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT

 

In consideration of receiving a piercing service from Piercings by Jenn LLC dba Curated, the Practitioner located at Curated Private Studio in Murrieta, CA.

I confirm the following by initialing on each line


I am not under any type of doctor care for Diabetes, Cardiac Valve Issues, bleeding issues, hemophilia, or anemia. Or I am not taking any medication that can cause excessive bleeding. I am not required to take any medications such as antibiotics before any dental or medical procedure. I am not pregnant if applicable


I am not under the influence of any kind including but not limited to: Alcohol, drugs both prescribed & illicit that would alter my decision making. I am not allergic to any latex or antibiotics. I do not have any other risk factors for blood borne pathogen exposure. You ever had a herpes outbreak in the area being pierced? If you do have any of the following, please stop filling out form and speak to your Artist.


I am the person, of legal age, that ID was presented and that I am at least 18 years old, or a parent or legal guardian will be required to provide their Identification as well.


I understand that there is always a chance of allergy, rejection,or failure of the Tattoo. Even with full and proper piercings, aftercare and all there is always a chance that my body will not tolerate the piercing


 I understand there is always a possibility of contracting an infection and that I have been advised on when to seek proper medical care.


I agree to follow all aftercare instructions, that includes both the piercing aftercare and healing time requirements before changing the piercing.


 I understand that I may feel lightheaded or dizzy before, during or even after the procedure, I have eaten and been well hydrate before my piercing appointment today. I will notify my piercer immediately if I start feeling ill.


 I understand that under extreme circumstances, nerve damage, bleeding, bone or tooth loss, tissue damage or scarring. While the jewelry can be removed, there is a potential for scarring which results in a permanent change to the body


I understand that although the piercer will do everything in their power to prevent this from happening, but they are not responsible for any negative outcomes. Please seek medical care immediately if you are seeing any signs of infection.


I will receive aftercare instructions from the piercer both verbally and printed. Also be aware that the aftercare will be available on our Instagram & Website


 I understand that under certain circumstances, photography both still and video may be used in promotional uses. This will include but not limited too TikTok, Instagram, Facebook, Google, Yelp…etc. If you chose to not be photographed, please inform your piercer, we will not use your images. There is monitoring by surveillance, via video at all times for the safety of our staff. No images from this will be used for social media purposes.

I,__________________________________ have been fully informed of the risks associated with the piercing I have hosen to receive. Including but not limited to, infection, other medical complications, allergic reactions, latex or iodine allergy, and the [possible use of antibiotics. Having been informed I still wish to proceed with the piercing.

 

Piercing Clients
AdultMinor
Continue
First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!