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X-Treme Ink Tattoo
22 East Market Street
West Chester, Pa 19382

Consent to application of PIERCING and release and waiver of all claims.

I acknowledge by signing this document that I have been given the full opportunity to ask any and all questions that I might have about obtaining a piercing from X-Treme Ink Tattoo. Also, I acknowledge that all of my questions were answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and agree as follows.

Please INITIAL all that apply:

I am eighteen (18) years of age or older. Piercings are given to minors ONLY with parental consent and attendance during the procedure.

 

I am not pregnant. If you are, we cannot pierce you. PERIOD! 

 

I am free from all communicable diseases (Hepatitis A, B, C, HIV, AIDS, etc.). If you are not, please inform your piercer. 

 

I do not have an allergy to nickel. If you do, please inform the piercer. 

 

Although X-Treme Ink uses all proper sanitation and sterilization processes (Hospital grade chemicals and autoclave), I understand that there is a risk of infection and compliance with our aftercare instructions is absolutely imperative to prevent this. 

 

I understand that, although rare, there is a risk of allergic reaction from the processes used to obtain a piercing. 

 

The obtaining of this piercing is by my choice alone and I consent to the application and to any actions or conduct the associates, agents, or representatives of X-Treme Ink Tattoo feel are necessary to perform the piercing. 

 

I agree to release and forever discharge and hold harmless X-Treme Ink Tattoo and its associates, agents, representatives, and shareholders from any and all claims , damages, or legal actions arising from or connected in any way with my obtaining of the piercing or the procedures and consent used to apply my piercing. 

 

Credit/Debit/Gift cards have a convenience charge of $2. 

 

***Relax and sit still during the piercing. Moving can negatively affect the piercing process.***

***No phone calls, face time, or live videos while being pierced***

Today's Date: September 18, 2021 

First Participant's Name

First Name*

Middle Name

Last Name*

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Second Participant's Signature*
Third Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Third Participant's Signature*
Fourth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

Middle Name

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
Tenth 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*

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*
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*

Middle Name

Last Name*

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

Please list medications, allergies, and medical conditions that may impact the piercing process.
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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