Loading...

Welcome to the Industrial Tattoo and Piercing

Online Body Piercing Release Form!

Please read the following thoroughly. After completing the waiver, you will be required to provide any and all forms of Valid ID to the Industrial Counter Staff up arrival, prior to being pierced! For examples of Valid Identification, please visit our website www.IndustrialTattooAndPiercing.com

Please select the piercee
AdultMinor
Continue
First Clients Name

First Name*

Last Name*

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

Email*

Confirm Email*
Eating and Blood Sugar Levels
We require that you will have eaten within 4 hours prior to the piercing procedure to maintain blood sugar levels.*
I understand
I don't understand why this is important. (We may send you to grab a snack before receiving a piercing)
Blood-born Pathogens
Do you have any blood-born pathogens, transmittable diseases or recent illnesses? (It is okay if you do! We just need to know for the safety of anyone that is involved.)*
No
Yes
Risks
I understand that prior to being pierced, I will be fully informed of the risks associated with receiving a piercing. I also understand that I am free to ask my piercer or the counter staff about the risks at anytime throughout the process, prior to getting pierced. I understand that these risks, known and unknown, can lead to injury, including, but not limited to infection, scarring, and keloiding and allergic reactions. I still wish to proceed with the piercing and understand that I freely accept all risks that may arise from receiving a piercing.*
No
Yes
Release
By checking 'Yes', I waive and release to the fullest extent permitted by law, each of the Piercer and 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 Piercer or Piercing Studio, or otherwise.*
No
Yes
Questions
I understand that both the Piercer and the Piercing Studio allow me the full opportunity to ask any and all questions about the piercing procedure and they can and will be answered to my total satisfaction.*
No
Yes
Aftercare
I understand that I will be given proper aftercare instructions prior to receiving a piercing. I acknowledge that it is possible that the piercing can become irritated or infected, particularly if I do not follow instructions.*
No
Yes
Duress
By checking 'Yes', I affirm that I am not under the influence of alcohol or drugs, and that I am voluntarily receiving a piercing without duress. ("Duress" n - threats, violence, constraints, or other action brought to bear on someone to do something against their will or better judgment.)*
No
Yes
Medical Conditions
By checking 'Yes', 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 preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as piercing.*
No
Yes
I have diabetes and should disclose this information to the piercer
I am not pregnant or nursing.*
No
Yes
Permanent Change
By checking 'Yes', 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-pierced condition even after it's removal*
No
Yes
Photography and Videography
By checking 'Yes', I release all rights to any photographs or video taken of me and the piercing and give consent in advance to their reproduction in print or use in social media platforms such as Instagram, Facebook, or any other social media platforms used by the Piercing Studio, artists, or piercers. (We just want to show off how beautiful our customers are!)*
No
Yes
This Release Form
By checking 'Yes', 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.*
No
Yes
Pronouns

Which pronouns do you use?
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 the parental/guardian signature they, on my behalf, release all claims that both they and I have.
Parent or Guardian Name

First Name*

Last Name*

Phone*
Parent or Guardian Date of Birth*
Parent or Guardian 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