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STATE OF TEXAS HEALTH DEPARTMENT BODY
PIERCING CLIENT CONSENT RECORD:MINOR
ON BEHALF OF
PRESTIGIOUS PIERCING, LLC

COPY OF IDENTIFICATION: 18+ (STATE/REGION/PROVINCE/TERRITORY/CITIZEN/RESIDENT/VISA/PASSPORT) MINORS: 5+ (PASSPORT/SCHOOL/PARENT/BIRTH CERTIFICATE)

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.


I further acknowledge that Prestigious Piercing has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.


I further acknowledge that Prestigious Piercing can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, studio staff, and other studio clients and their families. I voluntarily seek services provided by Prestigious Piercing and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.


I attest that:

  • I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
  • I have not traveled internationally within the last 14 days. I have not traveled to a highly impacted area within the United States of America in the last 14 days.
  • I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
  • I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
  • I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
  • I understand that I will be required to provide and wear a proper face mask during my entire visit.
  • I understand that I will be asked to wash or sanitize my hands upon entering the studio


I understand and accept the possible risks and dangers associated with receiving a body piercing. These risk and dangers include, but are not limited to, at least The possibility of discomfort or pain;The possibility of scarring;The possibility of bleeding;The possibility of swelling;The risk of infection;The possibility of nerve damage; and; The increased risk for adolescents during certain stages of development.


NO PERSON MAY BE BODY PIERCED WHO APPEARS TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS.

An artist may not perform body piercing on a person younger than 18 years of age without the consent of a parent, managing conservator, or guardian and meeting the requirements of 25 Texas Administrative Code, §229.406(e).

I attest that:

  • I am not pregnant or nursing.
  • I do not have epilepsy or hemophilia.
  • I do not suffer from any heart conditions or take medication which thins the blood.
  • I have informed my piercer of any condition such as diabetes that might hamper healing of the piercing.


If I suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advised of any procedures necessary to promote the satisfactory healing of my piercing.

I 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 the piercing.

I have advised the Piercer of any allergies to metals, latex, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.


I have truthfully represented to the Studio my age and identity. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.


I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my 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.


I acknowledge that Prestigious Piercing will document the process of the piercing or the result and jewelry, and these photos will be used but not limited to marketing/advertising purposes, educational, etc. I understand that I have the right to deny having myself documented and photos being taken.


I understand I will be pierced using appropriate instruments and sterilization. Therefore, I request the Piercer to pierce me. I understand a piercing usually takes 6 months to a year to heal. I agree to release and forever discharge and hold harmless Prestigious Piercing 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 my piercing.


I have received a copy of applicable written care instructions and I have read and understand such written care instructions. *I hereby release and agree to hold Prestigious Piercing harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the studio, or that may otherwise arise in any way in connection with any services received from Prestigious Piercing. I understand that this release discharges Prestigious Piercing from any liability or claim that I, my heirs, or any personal representatives may have against the studio with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Prestigious Piercing. This liability waiver and release extends to the studio together with all owners, partners, and employees. 


STATE OF TEXAS HEALTH DEPARTMENT BODY
PIERCING PARENTAL CONSENT AFFIDAVIT

I hereby allow and request Prestigious Piercing to pierce my son and/or daughter. In consideration of doing so, I fully understand the piercing does not act as a medical professional. Any suggestions made to me are NOT to be construed as/or substituted for advice from a medical professional. I acknowledge by signing this Release I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing and all my questions have been answered to my full and total satisfaction. I acknowledge I have been advised of the matters set forth below and I agree as follows:

*My child is not pregnant or nursing. He/She does not have any condition that might hamper healing of the piercing. He/She does 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 the piercing.

*I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether He/She might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.

*My Child is not under the influence of drugs or alcohol. To my knowledge, He/She does not have any physical, mental or medical impairment or disability which might affect his/her well-being as a direct or indirect result of my decision to have a piercing done at this time.

I acknowledge that obtaining this piercing is my child's choice alone and will result in a permanent change to his/her 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.

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 of them while the piercing is healing.

I acknowledge that Prestigious Piercing will document the process of the piercing or the result and jewelry, and these photos will be used but not limited to marketing/advertising purposes, educational, etc. I understand that I have the right to deny having myself documented and photos being taken.

I understand he/she will be pierced using appropriate instruments and sterilization. Therefore, I request the Piercer to pierce my son/daughter. 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 his/her piercing.
• State of Texas County of Nueces

Under penalty of perjury, I, the “parent”, declare the following:

• Participant is my minor child.

• The minor’s identity must be recorded.

• The parent’s identity must be recorded.

• Other materials presented demonstrating the status of the parent, managing conservator, or guardian must be recorded.

• I have the authority to consent to the body piercing of my child.

• I have presented identification of myself and my minor child to the manager/artist of this establishment.

• I agree to remain present with my minor child during the entire procedure of body piercing.

*I hereby release and agree to hold Prestigious Piercing harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the studio, or that may otherwise arise in any way in connection with any services received from Prestigious Piercing. I understand that this release discharges Prestigious Piercing from any liability or claim that I, my heirs, or any personal representatives may have against the studio with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Prestigious Piercing. This liability waiver and release extends to the studio together with all owners, partners, and employees.

Parent Signature:

DATE: May 9, 2024

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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Signature*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
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Country:*
City:*
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Parent or Guardian's Email Address

Email*

Confirm Email*
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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 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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