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Piercing Release Form

I hereby induce the staff of Mint Body Piercing to perform a piercing; and in consideration of doing so, I hereby release the piercer and Mint Piercing Studio from all manner of liabilities, claims, actions and demands in law, or in equity, which I or my heirs might now or hereafter by reason of complying with my request to be pierced. I fully understand that the body piercer, in performing a piercing, does not act in the capacity of a medical professional. The suggestions made by the piercer are just suggestions. They are not to be construed as, or substituted for, advice from a medical professional. I understand that I will be pierced using appropriate aseptic technique, sterilized equipment and jewelry. I also understand that infections/irritations can occur due to lack of proper hygiene and/or metal sensitivities. I understand that this piercing may leave noticeable, permanent scarring. To ensure proper healing of my piercing, I agree to follow the aftercare procedures suggested in the verbal/written aftercare sheet provided.

I will inform the piercer if I have any of the following: diabetes, hemophilia, high blood pressure, epilepsy, seizures, or narcolepsy.

I Agree

I am not pregnant or nursing.

I Agree

I have not taken medication to thin blood or stop clotting.

I Agree

I am not currently under the influence of alcohol or drugs.

I Agree

I do not have any conditions which might affect the execution or healing of this piercing.

I Agree

I consider myself healthy enough to heal this piercing.

I Agree

I will be able to keep the initial piercing jewelry in at all times during the healing period.  This includes even short periods of time for sports or medical procedures. 

I Agree

I agree to allow any photos taken of me at Mint Piercing Studio to be used for promotional and instructional purposes.  Mint staff will not take any photos without your verbal consent as well.

I Agree

COVID-19 Assumption of Risk and Waiver of Liability 

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. ​COVID-19 is extremely contagious​ and is believed to spread mainly from person-to-person contact.

Mint Piercing ​(“the Facility”) ​has put in place preventative measures to reduce the spread of COVID-19; however, infection from COVID-19 can happen anywhere and ​no business can guarantee​ ​or completely prevent ​someone from becoming infected. Further, ​being in any business could ​increase​ your risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering the Facility and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Facility may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Facility employees, contractors, representatives.

I Agree

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with being in the Facility and/or receiving services (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless the Facility, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Facility, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after receiving services within the facility.

I Agree

 

 

 

 

Please select who will be getting pierced
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First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Clients 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*

Confirm Email*
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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*

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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