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SIX16 Body Piercing & Fine Jewelry  

BODY PIERCING RELEASE FORM

 

I hereby release SIX16 Body Piercing & Fine Jewelry and its employees and agents, from all manner of liabilities, claims, actions and demands, in law or in equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to have a piercing performed.

I FULLY UNDERSTAND that any employee or agent of SIX16 Body Piercing & Fine Jewelry when performing a body piercing does not act in the capacity of a medical professional. The suggestions made by any employee or agent of SIX16 Body Piercing & Fine Jewelry are just suggestions. They are not to be construed or substituted for advice from a medical professional.

I UNDERSTAND MY BODY PIERCING WILL BE PERFORMED using appropriate instruments and techniques. To ensure proper healing of my piercing, I agree to follow the suggestions outlined in the written body piercing-specific aftercare instructions provided to me until healing is complete. I hereby assume full responsibility for aftercare and cleanliness. I understand that by having this body piercing performed that I am making a permanent change to my body and no claims have been made regarding the ability to undo the changes made.

I WILLINGLY SUBMIT TO THESE PROCEDURES, with a full understanding of possible complications such as, but not limited to: infection, allergic reaction, rejection, and potential of surgical removal of the piercing.

 

                        PLEASE ANSWER THE FOLLOWING QUESTIONS SO THAT WE MAY BETTER SERVE YOU

 

I am not currently sick (COVID-19, common cold, flu, stomach bug, ear infection, strep throat, skin infection, etc.)
*I will let the staff of SIX16 know about any recent illness within the past two weeks prior to my appointment     

I Agree
 

I will let the staff of SIX16 know about any conditions that may affect the procedure or healing of this piercing.   

I Agree

I will let the staff of SIX16 know about any allegries I may relevant to my piercing procedure  

I Agree

I will let the staff of SIX16 know about any medications I am taking that may interfere with the healing of my piercing  

I Agree

I have eaten a sufficent meal in the last 4 hours.    

I Agree
        

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

I Agree

I am not prone to fainting   

I Agree
                                         

I am not prone to heavy bleeding   

I Agree
                                    

I have not taken any blood thinners in the past 8 hours   

I Agree
              

I am not pregnant or nursing.   

I Agree
   

 


 

 

 

Please select who will be getting pierced
AdultMinor
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First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Information
Preferred Pronouns*
She / Her
He / Him
They / Them
Other (please feel free to inform us at your discretion)
I'd rather not say
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*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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(s) or court-appointed legal guardian(s) must bring valid Identification and proof of relationship to the minor. (EX: State ID and Birth Certificate / Court - appointed guardianship paperwork) **See FAQ on our website for more details**


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 Information
Preferred Pronouns*
She / Her
He / Him
They / Them
Other (please feel free to inform us at your discretion)
I'd rather not say
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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