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ROSE GOLD'S TATTOO & PIERCING

CONSENT TO PROCEDURE AND RELEASE OF LIABILITY

I hereby authorize Perry Doig, Alana Paris or any representative body piercer at Rose Gold's Tattoo & Piercing to perform upon myself the procedure of piercing. I understand that this piercing(s) usually takes 3-6 months or longer to heal and that heal times vary from person to person.

  • This procedure is to include whatever is required in attempting to accomplish such purpose and if any conditions are revealed during the course of 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.
  • The nature and purpose of this procedure, possible alternative methods, the risk involved, and the possibility of 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 gold, surgical stainless steel, niobium or titanium is ideal for this procedure and I have made the decision to use jewelry made of 14 karat gold, surgical stainless steel, titanium, or glass and I accept all responsibility for this decision.
  • I hereby certify that I am not being coerced in any way, and I am requesting this procedure of my own free will.
  • 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 prior to use and are safely and properly disposed of after each client.
  • I acknowledge that certain medical conditions and treatment 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 weaken the immune system.
  • I acknowledge it is not reasonably possible for the representatives and employees of this shop to determine whether I might have an allergic reaction to the processes used in my piercing and I agree to accept the risk that such a reaction is possible.
  • I understand and agree to the aftercare suggestions that were provided to me via paper copy.
  • 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 suggested to get pierced if I play sports including contact sports or competitions that would require me to remove my jewelry and that jewelry should not be removed or covered with bandages at all until fully healed. 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 final sale, there will be no refunds or exchanges on jewelry once the jewelry is inserted into my body. I understand that once jewelry is inserted into my piercing, that I am obligated to pay for the jewelry in it's entirety. I understand that it is my responsibilty to ask for the price of jewelry before it is inserted into my piercing and agree to pay for the jewelry in full. Furthermore, I understand that jewelry should be cared for with daily maintanance and Rose Gold's Tattoo & Piercing will not be liable for lost or broken jewelry under any circumstance. 
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for you
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for 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
A signed copy of this waiver will be sent to the email address you provide.
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
I am over the age of 18 years old.*
No
Yes
Have you eaten within the past 4 hours?*
No
Yes
Are you currently using or have you recently used medications that contain a controlled substance?*
No
Yes
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?*
No
Yes
Have you ever been diagnosed by a medical doctor as having allergies?*
No
Yes
Are you currently pregnant or breastfeeding?*
No
Yes
Do you suffer from heart conditions or take medications which thin the blood?*
No
Yes
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?*
No
Yes
Have you recently been diagnosed by a medical doctor as to having a disease that could affect the healing process, including diabetes?*
No
Yes
Are you currently under the influence of any illegal substances?*
No
Yes
Are you currently under the influence of an alcoholic beverage?*
No
Yes
Have you been diagnosed with jaundice within the past twelve months?*
No
Yes
Are you currently using any medications that weaken the immune system that fights infections?*
No
Yes
Have you had this exact piercing before?*
No
Yes

Name that we should call you, if different than legal name.

Pronouns that we should use for 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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