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Kyklops LLC

2130 E Carson Street

Pittsburgh, PA 15203

WAIVER, RELEASE, AND CONSENT TO BODY PIERCING 

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

PLEASE READ EACH PROVISION CHECK THE BOX TO AGREE TO EACH PROVISION OR INITIAL.

In consideration of obtaining a piercing from Daria Fiochetta or Kat Pulfer (the “Piercer”) at Kyklops LLC (together with its employees, apprentices and agents, the “Piercing Studio”), I agree to the following:

 

I am of legal age and am competent to sign this Agreement.

I Agree

 

I agree to comply with all Piercing Studio policies and rules, including but not limited to proper donning of a face covering, handwashing, hand sanitizing, signage, and instructions. Because the Piercing Studio is open for use by other individuals, I recognize that I am at higher risk of contracting COVID-19.

I Agree

 

I have been fully informed of the inherent risks, associated with receiving a piercing. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, and allergic reactions to piercing jewelry, latex gloves, and/or soap. Having been informed of the potential risks associated with receiving a piercing, I still wish to proceed with being pierced and I freely accept and expressly assume any and all risks that may arise from piercing.

I Agree

 

I agree to waive and release to the fullest extent permitted by law each of the Piercer and the Piercing Studio from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from being pierced, whether caused by the negligence or fault of either the Piercer or the Piercing Studio, or otherwise. 

I Agree
 

 

Both the Piercer and the Piercing Studio have given me the full opportunity to ask any and all questions about my piercing and all of my questions have been answered to my total satisfaction. 

I Agree
 

 

By having this piercing performed, I am making a permanent change to my body and no claims have been made regarding the ability to undo any changes made. 

I Agree

 

The Piercer and the Piercing Studio have given me instructions on the care of my piercing while it’s healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. If my piercing needs to removed or re-pierced due to my own negligence, I agree that the work will be done at my own expense. 

I Agree

 

I agree to reimburse each of the Piercer and the Piercing Studio for any attorneys’ fees and costs incurred in any legal action I bring against either the Piercer or the Piercing Studio and in which either the Piercer or the Piercing Studio is the prevailing party. I agree that the courts of Pennsylvania in Allegheny County shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement. 

I Agree

 

I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against the Piercer and the Piercing Studio. 

I Agree

 

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be pierced by the Piercer without duress or coercion. 

I Agree

 

I release all rights to any photographs taken of me or any minors in my custody and the piercing and give consent in advance to their reproduction in print or electronic form. (If I would prefer not to be photographed, I will indicate my preference in the next section.)

I Agree

 

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

I Agree

 

I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract waiving certain rights to recover against  the Tattoo Studio. I have read this agreement, I understand it, and I agree to be bound by it.

I Agree

 

I certify under penalty of perjury that the above information is true and correct. I further understand that, if I give false information or produce false documents stating my name and age to be other than what is correct, then I am liable for prosecution. 

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Second Participant's Signature*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Third Participant's Signature*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
Tenth Participant'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*
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Pronoun (Optional):
He
She
They
Other

If Other:

Please answer the following questions, so we can ensure you the best possible experience.

Have you eaten in the last 4 hours?*
No
Yes
Are you anemic?*
No
Yes
Are you prone to fainting?*
No
Yes
Are you prone to heavy bleeding?*
No
Yes
Have you taken aspirin, ibuprofen or anticoagulants in the last 24 hours?*
No
Yes
Are you allergic to latex or iodine?*
No
Yes
Do you have any other allergies? ______________________________*
No
Yes

If Yes, list
Do you have Mitral Valve Prolapse or any other heart condition that requires antibiotics before dental work or other medical procedures?*
No
Yes
Are you pregnant or nursing?*
No
Yes
Do you have any other conditions that may affect the procedure or healing of your piercing?*
No
Yes
Have you consumed any drugs or alcohol in the last 24 hours?*
No
Yes
Have you had contact with anyone with a confirmed case of COVID-19 or have you worked in a facility with any recognized COVID-19 cases?*
No
Yes
Do you have either of these respiratory symptoms?
Cough
Shortness of breath
Do you have any of these symptoms?
Fever
Repeated shaking with chills
Headache
New loss of taste or smell
Diarrhea
Chills
Muscle pain
Sore throat
Vomiting
Have you traveled within the last 14 days?*
No
Yes

If yes, where have you traveled?
Which piercing(s) are you getting? *
Face-Eyebrow
Face-Bridge/Earl
Ear--Helix
Ear--Flat
Ear--Conch
Ear--Orbital
Ear--Lobe
Ear--Tragus
Ear--Anti-tragus
Ear--Daith
Ear--Snug
Ear--Rook
Ear--Industrial
Body-Nipple
Body-Navel
Body-Dermal Anchor
Body-Genital
On which side of your body is your piercing going?*
Right side
Left side
Both sides
Center/ Not applicable
Photographs (optional):
I would prefer NOT to be photographed.
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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