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ROSE GOLD'S TATTOO & PIERCING

CONSENT TO PROCEDURE AND RELEASE OF LIABILITY

I hereby authorize ORIO GUEVARA, BEN MATTHEWS or representative tattoo artist of Rose Gold's Tattoo & Piercing, to tattoo me. In consideration of doing so, I hereby release said tattoo artist, ROSE GOLD’S TATTOO & PIERCING, their employees, agents, owners, and heirs from all manner of liabilities, claims, actions and demands, in law or equity, whether arising from negligence or any other manner. I have received and read an Aftercare Instruction sheet and assume full responsibility for my own care after each session is completed. I understand that my tattoo will take 2 to 4 weeks to heal, though individual healing times will vary.

  • I understand that the needles used for my tattoo are single-use. They have not been used on any other clients. The needles have been autoclaved prior to use and are safely and properly disposed of after each client. -I understand that all equipment used for my tattoo has been sanitized/sterilized prior to use.
  • I acknowledge that I am aware certain medical conditions and treatment and/or medications used to treat those conditions may be adversely impacted by the procedure(s) of tattooing. Such medical conditions include, but are not limited to, impaired kidney and/or liver function, diabetes, jaundice, medication containing blood thinners and medication that weaken the immune system.
  • I acknowledge that infection is always possible as a result of obtaining a tattoo, especially if I do not take proper care of it. I agree that any touch-up, due to my own negligence, will be done at my own expense.
  • I acknowledge it is not reasonably possible for the representatives and employees of this tattoo shop to determine whether I might have an allergic reaction to the pigments or processes used in my tattoo and I agree to accept the risk that such a reaction is possible.
  • I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my tattoo.
  • The obtaining of this tattoo is by my choice alone. I consent to the application of the tattoo and to any actions or conduct necessary to perform the tattoo.
  • I realize that variations in color and design may exist between any tattoo as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin.
  • I further acknowledge that the tattoo should be considered PERMANENT; that said tattoo can only be removed with a medical procedure; and that any effective removal may leave permanent scarring and disfigurement. 
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
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
A signed copy of this waiver will be sent to the email address you provide.
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*

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

PLEASE READ EACH QUESTION FULLY & ANSWER HONESTLY. 

Are you at least 18 years old or older? *
YES
NO
Have you eaten a full meal within 4 hours before your appointment? If not, please do so. *
YES
NO
Have you, or anyone in your household, exhibited any signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Have you, or anyone in your household, been around someone that was exhibiting signs or symptoms of illness in the 2 weeks prior to your appointment? *
YES
NO
Are you or anyone in your household a healthcare worker who works in an emergency room, hospital or office setting where you are exposed for any length of time to individuals with Covid-19 or any other contagious viruses or illnesses?
YES
NO
Have you, or anyone in your household, traveled to or from out of state or been on an airplane in the 2 weeks prior to your appointment? *
YES
NO
Do you currently have any condition, unrelated to illness, that might cause you to cough or sneeze? (Allergies, Asthma or other lung disorders etc..) *
YES
NO
Are you currently pregnant or breastfeeding? *
YES
NO
Have you ever been diagnosed by a medical doctor as having allergies? *
YES
NO
Have you recently been diagnosed by a medical doctor as to having a disease that could effect the healing process, including diabetes? *
YES
NO
Have you ever been diagnosed by a medical doctor as having contracted a communicable disease such as immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and/or other blood borne pathogens? *
YES
NO
Do you have any heart conditions or take medications which thin the blood? *
YES
NO
Are you currently using or have you recently used medications that contain a controlled substance? *
YES
NO
Are you currently using any medications that weaken the immune system that fights infections? *
YES
NO
Have you been diagnosed with jaundice within the past twelve months? *
YES
NO
Do you have any physical/mental/medical impairment or disability which might affect your well-being as a direct or indirect result of my decision to have a piercing done at this time? *
YES
NO
Are you currently under the influence of any, or have you taken any illegal substances in the 24hours prior to your appointment? *
YES
NO
Are you currently under the influence of, or have you consumed any alcoholic drinks in the 24hours prior to your appointment? *
YES
NO

Pronouns that we should use for you

Name that we should call you, if different than legal name.
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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