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CONSENT TO BODY PIERCING PROCEDURE

 


I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a body piercing or microdermal (single point piercing) and that all of my questions have been answered to my full satisfaction. I also acknowledge that I may be pierced by an apprentice. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows:

*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 the 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, infections, rashes, 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 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 trustfully represented to the Piercer that I am over the age of eighteen (18) years. 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 restore the skin involved in this piercing to is pre-piercing condition.


*I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and agree to follow all of them while my piercing is healing.
 



 

*I understand that a microdermal (single point piercing) consists of a pierced point of entry but not a point of exit. Specially designed jewelry is inserted into the pierced area and sits below the skin where it becomes anchored.

*I understand I will be pierced using appropriate instruments and sterilization.

* I understand this type of piercing usually takes 3 months or longer to heal.


 

I hereby release and forever discharge and hold harmless the Piercer and all affiliates, Owners, Managers, and 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, to the fullest extent allowed by the law.

By signing below, I agree that I have read the Body Piercing Release form provided by 1Eleven Tattoo Collective and agree to these terms.

IMPORTANT: It is MANDATORY to provide proof of Identification. Please submit a government issued photo ID.


 

COVID-19 RELEASE FORM QUESTIONS

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. 1Eleven Tattoo Collective, LLC ("the Facility") has put in 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. 

 

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 confirm that I am not presenting any of the symptoms of COVID-19 including

dry cough
runny nose
sore throat
shortness of breath
loss of sense of taste or smell
fever.


I confirm that I have not been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days. 


 

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have not traveled outside of or domestically within the past 14 days. 

 



 

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Phone*
Participant's Date of Birth*
Date of Birth
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*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Choose below
Piercing Type
Belly Button
Cartilage
Conch
Cristina & Clitoris
Daith
Dermal
Ear Lobe
Industrial
Infant/Child Ear Lobe
Lip
Medusa
Nipple pair
Nipple
Nose Double
Nose
Rook
Septum
Smiley
Surface Tragus
Tougue
Tragus
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*
Phone*
Parent or Guardian's Date of Birth*
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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