Loading...

CONSENT WAIVER FOR PIERCINGS ONLY

 

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

 

---------------------------------------------

I understand I will be pierced using appropriate instruments and techniques, and I acknowledge that infection is always possible as a result of obtaining a piercing. To ensure proper healing of my piercing, I agree to follow the directions given to me following my piercing procedure.  

I Agree

 

Health History and Informed Consent

The following conditions may increase health risks associated with receiving body art:

  1. I am not pregnant or nursing. I do not have epilepsy, diabetes or hemophilia. I do not suffer from any heart conditions or take medications that thin the blood. I am not under the influence of drugs or alcohol.
    I Agree
  2. If I suffer from hepatitis, HIV or other communicable disease, I have the opportunity to inform the piercer of this fact.
    I Agree
  3. I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.
    I Agree
  4. I have advised the piercer of any allergies to metals, pigments, latex, soaps, and medications. I acknowledge that it is not possible for the piercer to determine whether I might have an allergic reaction to the piercing or process involved in the piercing and further acknowledge that such a reaction is possible.
    I Agree
  5. 5. I have trustfully represented to the piercer that I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.
    I Agree
  6. I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to restore the skin involved in this piercing to its pre-pierced condition.
    I Agree
  7. I understand that if I have had a herpetic outbreak in the past that the stress of this procedure may result in a herpetic flare-up.
    I Agree
  8. I do not have mitral valve prolapse or any other heart condition that requires antibiotics before dental work or any other medical procedure.
    I Agree
  9. I have eaten in the last 4 hours.
    I Agree

By my signature below, I certify that if I give false information or produce false documentation stating my name and age to be other than correct, then I am liable for prosecution.


Date: December 21, 2024

Disclosure Statement

  • As with any invasive procedure, piercing may involve possible health risks. These risks may include: pain, bleeding, swelling, infection, scarring of the area, and nerve damage.
  • Unsterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before use.
  • The Body Art practitioner should properly and thoroughly cleanse the area before the procedure, use sterile equipment, use sterile techniques, and provide information on the aftercare of the area receiving body art.
  • Aftercare available at http://www.luckystattoo.org/piercing-aftercare
  • You may not be allowed to donate blood either temporarily or permanently. I have read and understood this disclosure statement.


Date: December 21, 2024

If there are any questions, complications, injury, or infection such as heat, redness, swelling, green or yellow discharge, or disease as a result of this body modification procedure, please notify your artist.

This disclosure statement is as per the Northampton Board of Health 210 Main St. Room 8, Northampton MA 01060 (413) 587-1214


Please select who will be participating...
AdultMinor
Continue
First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Pronouns:

Preferred name:

Age *

Date of Birth *

Piercer's name (Zach, Alycia, Andie, Lindsay, Max, or Guest Piercer)



Area being pierced

I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be pierced, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept
Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the piercing. 

I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form. (If you do not accept this provision, please advise and remind the piercer NOT to take any pictures of you)*
First Client's Signature*
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 be added to Lucky’s mailing list to receive exclusive promotional information and updates. (we will never rent, sell, or share your information!)
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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Pronouns:

Preferred name:

Age *

Date of Birth *

Piercer's name (Zach, Alycia, Andie, Lindsay, Max, or Guest Piercer)



Area being pierced

I hereby release Lucky's and its employees and agents from all manner of liabilities, claims, actions and demands, in law and equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be pierced, I fully understand that any employee or agent of Lucky's, when performing body modifications does not act in the capacity of a medical professional. Suggestions made by an employee or agent of Lucky's are not to be construed as, or substituted for, advice from a medical professional.

Accept
Accept

I understand that this type of modification usually takes 4-6 weeks or longer to heal. I willingly submit to these procedures with full understanding of possible complications such as, but not limited to; infection, allergic reaction, or bodily rejection of the piercing. 

I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form. (If you do not accept this provision, please advise and remind the piercer NOT to take any pictures of 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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!