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Prysm Body Piercing
1551 Valley West Dr. Suite 104B
West Des Moines, Iowa. 50266

Body Piercing Release Form 

I hereby certify that I am choosing to obtain a body piercing, jewelry insertion, or jewelry removal from Prysm Body Piercing under my own free will, and that I am not under the influence of any other person to do so, nor am I under the influence of any type of drug or alcohol. I understand all of the potential short and long term risks involved in body piercing, jewelry insertion, jewelry removal, the procedure and aftercare.

I Agree

I grant permission to a professional body piercer to pierce my body and insert or remove jewelry. In consideration of their doing so, I hereby release Prysm Body Piercing, its owners, 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 be pierced, jewelry inserted, or jewelry removed.

I Agree

I understand that the procedure(s) will be performed with appropriate instruments and techniques. To ensure proper healing, I agree to follow the aftercare procedures outlined to me, until healing is complete. I understand that the body piercer, in performing a piercing, insertion or removal does not act in the capacity of a medical professional. Any and all suggestions made by the piercer are solely suggestions and not a substitute for advice from a medical professional.

I Agree

In the event that photographs are taken, I hereby give Prysm Body Piercing, its employees, or agents permission to copyright and/or use, and/or publish images of me and/or my piercing. This includes reproductions made through any media format, or for any other lawful purpose whatsoever. I waive any right I may have to inspect the photograph and/or approve the finished product or the use to which it may be applied.

I Agree

I am not under the influencce of drugs or alcohol

I Agree

I will notify my Body Piercer at Prysm if I have any allergies (other than medications or environmental)

I Agree

I consider myself healthy enough to receive and heal this piercing

I Agree


Covid-19 Assumption of Risk
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. Prysm Body Piercing (“the Facility”) has put in place preventative measures to reduce the spread of COVID-19; however, infection from COVID-19 can happen anywhere and no business can guarantee or completely prevent someone from becoming infected. Further, being in any business could increase your risk of contracting COVID-19.

I Agree

To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facility’s guidelines. The facility’s guidelines can be changed at anytime as new information and technology become available.

I Agree

I confirm that I am not presenting any of the symptoms of COVID-19 including: dry cough, running nose, sore throat, shortness of breath, loss of sense of taste or smell, fever - temperature of 100.4 degrees or more.

I Agree

I confirm that I have not been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days. 

I Agree

I understand and agree that this release of liability includes any claims based on the actions, omissions, or negligence of the facility, its employees, agents and representatives, weather a Covid-19 infection occurs before, during or after receiving services within the facility.

I Agree

 

I declare under penalty of perjury, under the laws of the United States of America that the foregoing is true and correct. 


May 28, 2020

 

First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
First Clients Signature*
Second Clients Name

First Name*

Middle Name

Last Name*
Second Clients Date of Birth*
Second Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Third Clients Name

First Name*

Middle Name

Last Name*
Third Clients Date of Birth*
Third Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Fourth Clients Name

First Name*

Middle Name

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Fifth Clients Name

First Name*

Middle Name

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Sixth Clients Name

First Name*

Middle Name

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Seventh Clients Name

First Name*

Middle Name

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Eighth Clients Name

First Name*

Middle Name

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Ninth Clients Name

First Name*

Middle Name

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Tenth Clients Name

First Name*

Middle Name

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
Parent or Guardian's Email Address

Email*

Confirm Email*
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Are you pregnant or nursing?*
No
Yes
Do you have any skin conditions in the area being pierced? (ex. eczema, psoriasis, sunburn etc.)*
No
Yes
I have or suffer from
Diabetes
High blood pressure
Seizures
Hemophilia
Epilepsy
Narcolepsy
None of the above
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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