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ROSE GOLD'S TATTOO & PIERCING

CONSENT TO PROCEDURE AND RELEASE OF LIABILITY

I now authorize Perry Doig, Andrea Whipple, Ben Chavez, Frank Troeh, Manny Leon Guillen, or any representative body piercer at Rose Gold's Tattoo & Piercing to perform the procedure of piercing upon myself. I understand that piercing(s) can take anywhere from 3 to 9 months or longer to heal, and that healing times vary from person to person.

  • The nature and purpose of this procedure, as well as possible alternative methods, the risks involved, and the potential complications, have been fully explained to me. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained, and I assume any and all risks in connection therewith.
  • I understand this procedure involves the invasion of my body by an instrument and jewelry, and said instrument and all other instruments used in the course of this procedure are sterile, and that this procedure will be done using strict aseptic technique.
  • It has been explained to me that jewelry made of 14-karat &18-karat gold, niobium, or titanium is ideal for this procedure. I have decided to use jewelry made of 14-karat gold, 18-karat gold, titanium, or glass, and I accept full responsibility for this decision.
  • I hereby certify that I am not being coerced in any way, and I am requesting this procedure voluntarily.
  • I understand that the needles used for this procedure are single-use. They have not been used on any other clients. The needles, furthermore, have been autoclaved before use and are safely and properly disposed of after each client.
  • I acknowledge that certain medical conditions and treatments may be adversely impacted by the procedure(s) of this piercing. Such medical conditions include, but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners, and medication that weakens the immune system.
  • I acknowledge that it is not reasonably possible for the representatives and employees of this shop to determine whether I may have an allergic reaction to the processes used in my piercing, and I agree to accept the risk that such a reaction may occur.
  • I understand and agree to the aftercare suggestions that were provided to me via paper copy.
  • This procedure includes all necessary steps to achieve this purpose. If any conditions are revealed during this procedure that were not recognized before, and which call for procedures in addition to or different from those originally contemplated, I further request and authorize the performance of such procedures.
  • I understand that it is not suggested to get pierced before traveling, especially hiking/camping or swimming of any kind, and that I should refrain from these activities until the piercing is fully healed. 
  • I understand that it is not recommended to get pierced if I participate in sports, including contact sports or competitions, as this would require me to remove my jewelry.  Additionally, competitive sports that may cause my piercing to be hit or snagged should be avoided until the piercing is fully healed. 
  • I understand and accept that jewelry is a final sale; there will be no refunds or exchanges on jewelry once it has been inserted into my body. I understand that once jewelry is inserted into my piercing, I am responsible for paying for the jewelry in its entirety. I understand that it is my responsibility to ask for the price of the jewelry before it is inserted into my piercing and agree to pay for it in full. Furthermore, I understand that jewelry requires daily maintenance, and Rose Gold's Tattoo & Piercing will not be liable for lost or damaged jewelry under any circumstances. 
First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
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
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
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*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any illegal substances, drugs or alcohol? *
YES
NO
What name and pronouns should we use to address you?
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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