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ROSE GOLD'S TATTOO & PIERCING

CONSENT TO PROCEDURE AND RELEASE OF LIABILITY

I hereby authorize Manny Leon Guillen, Perry Doig, Andrea Whipple, Ben Chavez, Frank Troeh, or any representative body piercer at Rose Gold's Tattoo & Piercing to perform upon my child the procedure of piercing. We understand that this piercing(s) usually takes 3-6 months or longer to heal and that healing times vary from person to person.

  • This procedure is to include whatever is required in attempting to accomplish such purpose. If any conditions are revealed during the course of this procedure that were not recognized before, and which call for procedures in addition to or different from those originally contemplated, I further request and authorize the performance of such procedures.
  • The nature and purpose of this procedure, as well as possible alternative methods, the risks involved, and the potential complications, have been fully explained to me. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained, and I assume any and all risks in connection therewith.
  • We understand this procedure involves the invasion of my child's body by an instrument and jewelry, and said instrument and all other instruments used in the course of this procedure are sterile, and that this procedure will be done using strict aseptic technique.
  • It has been explained to me and my child that jewelry made of 18-karat, 14-karat gold, niobium, or titanium is ideal for this procedure. We have made the decision to use jewelry made of 18-karat gold, 14-karat gold, titanium, or glass, and I accept all responsibility for this decision.
  • I hereby certify that my child is not being coerced in any way, and they are requesting this procedure of their own free will.
  • We understand that the needles used for this procedure are single-use. They have not been used on any other clients. The needles, furthermore, have been autoclaved before use and are safely and properly disposed of after each client.
  • We acknowledge that certain medical conditions and treatments may be adversely impacted by the procedure(s) of this piercing. Such medical conditions include, but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners, and medication that weakens the immune system.
  • We acknowledge that it is not reasonably possible for the representatives and employees of this shop to determine whether I may have an allergic reaction to the processes used in my piercing, and we agree to accept the risk that such a reaction may occur.
  • We understand and agree to the aftercare suggestions provided to us via paper copy.
  • We understand that it is not suggested to get pierced before traveling, especially hiking/camping or swimming of any kind, and that my child should refrain from these activities until the piercing is fully healed. 
  • We understand that it is not advisable to get pierced if my child participates in sports, including contact sports or competitions, that require them to remove their jewelry. Additionally, competitive sports that may cause the piercing to be hit or snagged should be avoided until the piercing is fully healed, as premature removal of the jewelry can cause potential complications.
  • I understand and accept that jewelry is a final sale; there will be no refunds or exchanges on jewelry once it has been inserted into my child's body. I understand that once jewelry is inserted into my child's piercing, I am responsible for paying for the jewelry in its entirety. I understand that it is my responsibility to request the price of the jewelry before it is inserted into my child's piercing and agree to pay for the jewelry in full. Furthermore, I understand that jewelry requires daily maintenance, and Rose Gold's Tattoo & Piercing will not be liable for lost or damaged jewelry under any circumstances. 
Please select who will be participating...
Minor
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First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
My child is not pregnant or nursing. They do not have epilepsy or hemophilia. They do not suffer from any heart conditions or take medication which thins the blood. I will inform the piercer of any condition such as diabetes that might hamper healing o the piercing. *
Confirm
If they suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advized of any procedures necessary to promote the satisfactory healing of they piercing. *
Confirm
They 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 piercing. *
Confirm
I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for Piercer to determine whether they might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible. *
Confirm
My child is not under the influence of drugs or alcohol. To my knowledge, they do not have any physical, mental or medical impairment or disability which might affect their well-being as a direct or indirect result of my decision to have a piercing done at this time. *
Confirm
I acknowledge that obtaining this piercing is my childs choice alone and will result in permanent change to their appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition. *
Confirm
I acknowledge infection is always possible as a result of obtaining a piercing. My child and I have received aftercare instructions and We agree to follow all them while the piercing is healing. *
Confirm
I understand they will be pierced using appropriate instruments and sterilization. *
Confirm
Therefore, I request the Piercer to pierce my child. I understand this type of piercing usually takes 3-6 months or longer to heal. I agree to release and forever discharge and hold harmless the Piercer and all employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing or the procedure and conduct used in their piercing.*
Confirm
I will bring a government issued ID for myself and my child along with a birth certificate for verification. Passports, drivers license, ID or school ID are all valid forms of ID. *
Confirm
By my signature below, I certify that I am the parents of the child listed above, who is willingly submitting to these procedures. *
Confirm
What names and pronouns should we use when addressing you and your child?
First Participant's Signature*
Participant'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 or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
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.


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*
Date of Birth
Parent or Guardian's Information
My child is not pregnant or nursing. They do not have epilepsy or hemophilia. They do not suffer from any heart conditions or take medication which thins the blood. I will inform the piercer of any condition such as diabetes that might hamper healing o the piercing. *
Confirm
If they suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advized of any procedures necessary to promote the satisfactory healing of they piercing. *
Confirm
They 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 piercing. *
Confirm
I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for Piercer to determine whether they might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible. *
Confirm
My child is not under the influence of drugs or alcohol. To my knowledge, they do not have any physical, mental or medical impairment or disability which might affect their well-being as a direct or indirect result of my decision to have a piercing done at this time. *
Confirm
I acknowledge that obtaining this piercing is my childs choice alone and will result in permanent change to their appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition. *
Confirm
I acknowledge infection is always possible as a result of obtaining a piercing. My child and I have received aftercare instructions and We agree to follow all them while the piercing is healing. *
Confirm
I understand they will be pierced using appropriate instruments and sterilization. *
Confirm
Therefore, I request the Piercer to pierce my child. I understand this type of piercing usually takes 3-6 months or longer to heal. I agree to release and forever discharge and hold harmless the Piercer and all employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing or the procedure and conduct used in their piercing.*
Confirm
I will bring a government issued ID for myself and my child along with a birth certificate for verification. Passports, drivers license, ID or school ID are all valid forms of ID. *
Confirm
By my signature below, I certify that I am the parents of the child listed above, who is willingly submitting to these procedures. *
Confirm
What names and pronouns should we use when addressing you and your child?
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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