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Cambridge Jewelry Change Form

Don't forget to bring government issued photo ID with you to your appointment, its required!

 

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 

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. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people 

Lucky’s Tattoo and Piercing have put in place preventative measures to reduce the spread of COVID-19; however, Lucky’s Tattoo and Piercing cannot guarantee that you will not become infected with COVID-19. Further, getting a tattoo or piercing could increase your risk of contracting COVID-19. 

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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 Lucky’s Tattoo and Piercing 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 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Lucky’s Tattoo and Piercing employees. 

I voluntarily agree to assume all of the possible 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 my attendance at Lucky’s Tattoo and Piercing.

 

I hereby release, discharge, and hold harmless Lucky’s Tattoo and Piercing LLC,  its employees, agents, 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 Lucky’s Tattoo and Piercing employees, agents, whether a COVID-19 infection occurs before, during, or after participation in any tattoo, piercing work, or any other services provided by Lucky’s Tattoo and Piercing LLC.

 

I Agree

 

CLIENT HEALTH QUESTIONNAIRE 
PRIOR TO THE START OF MY SERVICE, I CONFIRM THAT: 

 

I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks.

I Agree

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks. 
I Agree

I have not traveled outside of my immediate daily routine for the past two weeks. 
I Agree

I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell. 
I Agree

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Lucky's Tattoo and Piercing as soon as possible.
I Agree

I will follow all posted studio rules to keep myself, studio staff, and those around me safe. 
I Agree

 

 

Release Form 

For Piercing Assessment, Stretching, Insertion, or Removal 

By signing this form, I induce Lucky's Tattoo & Piercing to STRETCH or ASSESS my previous piercing, or to INSERT or REMOVE jewelry into/from my previous piercing, and in consideration of doing so, I hereby release Lucky's Tattoo and Piercing 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 my piercing assessed, stretched, or to have my jewelry inserted/removed. Aftercare available at http://www.luckystattoo.org/piercing-aftercare

By my signature below, I give permission for said insertion/removal/stretching/assessment and I further understand that if I give false information or produce false documents stating my name and age to be other than correct, then I am liable for prosecution. 

Today's Date: May 26, 2022

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
Participant'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*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Area(s) previously pierced

How old is this/these piercing(s)?

Piercing Initially Performed at
Do you have any allergies to Latex?*
No
Yes
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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