Piercing Release Form

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Chameleon Tattoo and Body Piercing

36 JFK Street

Cambridge, MA

02138

Waiver of Liability Relating of Coronavirus/COVID-19

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. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Chameleon Tattoo and Body Piercing have put in place preventative measures to reduce the spread of COVID-19; however, Chameleon Tattoo and Body Piercing cannot guarantee that you will not become infected with COVID-19. Further, getting a tattoo or piercing could increase your risk of contracting COVID-19.

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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 Chameleon Tattoo and Body Piercing and that such exposure of 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 may result from the actions, omissions, or negligence of myself and others, including , but not limited to, Chameleon Tattoo and Body Piercing employees.

I voluntarily agree to assume all of the possible 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 my attendance at Chameleon Tattoo and Body Piercing.

I hereby release, discharge, and hold harmless Chameleon Tattoo and Body Piercing LLC, its employees, agents, 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 Chameleon Tattoo and Body Piercing employees, agents, whether a COVID-19 infection occurs before, during, or after participation in any tattoo, piercing work, or any other services provided by Chameleon Tattoo and Body Piercing LLC.

I Agree

Type Initials

Draw Initials

ALL PIERCING CLIENTS MUST SIGN AND RECIEVE A COPY OF THIS FORM, PRIOR TO ANY PIERCING PROCEDURE

PIERCING DISCLOUSRE STATEMENT AND CONSENT FORM

As with any invasive procedure, piercing may involve possible health risks.

These risks may include:

pain, bleeding, swelling;
scarring, hypertrophic scarring, and keloid formation;
possible nerve damage;
febrile (fever) illness;
tetanus; and
infection - local or systemic
- The use of unsterile equipment and needles can spread infectious disease; it is extremely important to be sure that all equipment is clean and sanitary before use.
- You may not be allowed to donate blood either temporarily or permanetly

The Piercing Practitioner will:

Properly and thoroughly cleanse the area before the tattooing procedure
Use sterilized equipment
Use sterile techniques
Provide information on the aftercare of the area receiving a piercing, available at https://www.chameleonbodyarts.com/after-care-piercing

HEALTH HISTORY

The following conditions may increase health risks associated with receiving a piercing:

diabetes;
hemophilia (bleeding);
skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.;
history of allergies or adverse reactions to pigments, dyes, or other sensitivities;
history of epilepsy, seizures, fainting or narcolepsy;
use of medications such as anticoagulants, (such as coumadin) which thin the blood and/or interfere with blood clotting; and
hepatitis or HIV infection

RECOMENDED INSTRUCTIONS FOR THE AFTERCARE OF PIERCINGS

Do not ever touch your new piercing - as long as you NEVER touch your piercing while it's healing, you will have no trouble with bacterial infection. Introducing your piercing to foreign bacteria is what causes infection, i.e.: touching money, doorknobs, and/or other people's hands, and THEN touching your piercing. No piercing gets infected on its own.
Items to buy for after care
- Neilmed piercingaftercare spray or comparable sterile saline wound wash: spray directly onto the piercing and air dry once or twice daily. If your skin becomes dry/ashy and feels itchy and right, just use solution once a day.
NEVER USE: Bacitracin or Neosporin. Petroleum based ointments CLOG the piercing and make it difficult for your body to heal.
NEVER USE: Rubbing alcohol, hydrogen peroxide, Claire's ear care solution, betadine, witch hazel, or hibiciens. These products are too strong and will irritate your skin and piercing.
Some swelling, rednes, and tenderness is normal during the healing process. If you ever experience redness in the area surrounding your piercing for 24 hours or more, PLEASE call to make an appointment to come show it to us right away!
You should contact your health care provider if you experience any unexpected redness, excessive redness, a rash, greenish discharge, or if you have a fever within 24 hours of the procedure.
OPTIONAL: sea salt and warm water soaking - soak your piercing three to five times a week in sea salt water for 5-15 minutes. Wash your hands, and place 1/8th of a teaspoon of sea salt in a shot glass or any small glass (8 oz), fill with very warm water, stir, lean forward, place the piercing over the glass, press the glass towards the body, lean back and let it soak.

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CLIENT CONSENT

I have read and understand the above information

I Agree

I do not have a condition that prevents me from recieivng a piercing

I Agree

I am not under the influence of any drug or alcohol

I Agree

I am not pregnant and don't suspect that I may be pregnant

I Agree

I consent to the performace of the piercing procedure and I have been given verbal and written aftercare insturctions as required by the Cambridge Body Art Regulation

I Agree

I am aware that all information disclosed will be kept confidential

I Agree

I am aware that a copy of this document will be provided to me

I Agree

Consult a health care provider for:

unexpected redness, tenderness or swelling at the site of the piercing
rash
unexpected drainage at or from the site of the piercing
fever within 24 hours of the piecring

PROCEDURE FOR FILING A COMPLAINT

If there is any sign of injury, infection, conplication or disease as a result of a piercing rocedure, first contact a healthcare provider for medical evaluation. Then notify this establisment and the CAMBRIDGE PUBLIC HEALTH DEPARTMENT, 119 WINDSOR STREET, CAMBRIDGE,MA 02139. Phone: (617) 665-3848

Please select who will be participating...

First Client Name

First Name*

Last Name*

Phone*

First Client Date of Birth*

First Client Information

Minor Form of ID (N/A if you are an adult)*

Please select the piercer you are working with*

Preferred pronouns of client*

First Client Signature*

Type Signature

Draw Signature

Client 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*

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

Minor Form of ID (N/A if you are an adult)*

Please select the piercer you are working with*

Preferred pronouns of client*

Parent or Guardian's Signature*

Type Signature

Draw 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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