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Piercing and Jewelry Change/Removal Release Form

I hereby induce the staff of Cold Steel America to perform a piercing or jewelry change/removal; and in consideration of doing so, I hereby release Cold Steel America and its employees and agents from all manner of liabilities, claims, actions, demands, in law or in equity, which I or my heirs have now or hereafter by reason of complying with my request to have services performed. I understand that the body piercer, in performing a piercing or jewelry change/removal, does not act in the capacity of a medical professional. The suggestions made by the piercer are just suggestions. They are not to be construed as, or substituted for, advice from a medical professional. 

I understand that my piercer will be using appropriate instruments and techniques. I also understand that infections/irritations can occur due to lack of proper hygiene and/or metal sensitivities. I understand that piercing may leave noticeable, permanent scarring. To ensure proper healing of my piercing, I agree to follow the aftercare instructions suggested in the verbal/written instructions provided for the entire healing period - which in some cases can take up to a year.

This information is private, for our records, and will not be shared with any companies. If you are currently in the care of a medical professional, we suggest consulting with them prior to being pierced, and in some cases a physicians note may be requested before piercing services can be provided.

I have eaten within the last 4 hours.

I Agree

I have not consumed alcohol within the last 8 hours.

I Agree

I will inform the piercer if I sometimes get lightheaded.

I Agree

I am not pregnant or nursing.

I Agree

I will inform the piercer if I have taken medication that thins the blood or stops clotting.

I Agree

I will inform the piercer if I have any medical conditions which may lead to the delay in healing, including but not limited to: diabetes, eczema, cardiac valve disease, psoriasis, hemophilia, high blood pressure, epilepsy, seizures, or narcolepsy.

I Agree

I will inform the piercer if I have any chemical, antibiotic, or latex allergies.

I Agree

I am not required to take antibiotics before any medical/dental procedures.

I Agree

COVID-19 Assumption of Risk and Waiver of Liability

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.

Cold Steel America ("the Facility") has put into 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.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering the Facility and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Facility may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Facility employees, contractors, or representatives.

I Agree

I voluntarily agree to assume all of the forgoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with being in the Facility and/or receiving services ("Claims"). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless the Facility, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Facility, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after receiving services within the Facility.

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 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, or fever.

I Agree

Please select who will be getting pierced or having jewelry changed/removed...
AdultMinor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Optional Information

Preferred Name (if different than legal name)

Pronouns
First Client's Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Client'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(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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Optional Information

Preferred Name (if different than legal name)

Pronouns
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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