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777 South 3rd St.
Jacksonville Beach, FL 32250
904-241-4231
carribbean-connection.com

December 15, 2018

BODY PIERCING CONSENT FORM

In accordance with Florida state law, any individual receive a body piercing MUST present valid government-issued ID.

For minors receiveing a piercing:

  • A person may not perform body piercing on a minor without the writtennotarized consent of the minor's parent or legal guardian, and an establishment may not perform body piercing on a minor under the age of 16 unless the minor is accompanied by a parent or legal guardian.
  • The parent must submit proof that he or she is the parent or legal guardian ofthe minor child.
  • Both the minor child and his or her parent or legal guardian must submit proof of his or her identity by producing a government-issued identification.
Please select who will be receiving a piercing...
AdultMinor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Check to receive exclusive e-mail updates about upcoming promotions and new product info.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Client Information
Please select: *
I am an adult (18 years of age, or older)
I am a minor (17 years of age, or younger)

For the following question, please select "Beaches Baptist" if you do not have a personal physician you'd like to list.

Personal Physician: *
Beaches Baptist / 1350 13th Avenue S., Jacksonville Beach, FL, 32250 / 904-627-2900
Other

If Other Personal Physician (include Name, Address, and Phone Number):

For the following fields, if none apply, please write in "N/A" or "None"


Allergies *

Bleeding Disorders *

Medical Condition/Diseases *

Medications *

Date of Piercing (Today's Date): *
Piercing Information

Body Piercing receiving today: *
Body Piercer:*
Cody Shores
Marin Day
This is to certify that I, the name above and undersigned, have represented the correct information as noted.
I fully understand that I must be 18 years of age or older, or I must have a signed and notarized parental/legal guardian permission form to obtain a body piercing.
I further understand that if I give false information or provide false documents stating my name and age, then I am liable for prosecution.
I am not under the influence of alcohol or drugs.
I accept full responsibility for any consequences that might stem from my decision to receive a body piercing.
I will not sue Carribbean Connection, employees or representatives of Carribbean Connection or any other company associated with Carribbean Connection.
I will receive a copy of "Body Piercing Aftercare Instructions" and verbal instructions, which I will read completely and hereby assume full responsibility for aftercare and cleanliness of my body piercing.
I understand that all work is done under strict hygienic conditions.
I am not pregnant.
Other Information
How did you hear about us? *
Walk-in
Return Customer
Facebook
Instagram
Other

If Other, please explain:
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.
Parent or Guardian's Name

First 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.


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