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PLEASE NOTE:

  • It is important to use these consent forms and consent letters in conjunction with applicable federal and state laws, as they apply to the standard of care required to provide such medical and cosmetic treatments.
  • These forms are meant for guidance only. We recommend that you use the forms in conjunction with individual legal counsel based on your individual situation, and not as a substitute for legal advice.
  • With that being said, we do want to clarify that the following is set of suggestions which should be used in conjunction with applicable laws. 

CONSENT FORM 

Thank you for choosing GET FUSED to create your permanent jewelry. In order to provide you with the best possible service and ensure your safety, we require that you complete this Intake and Consent Form.

Please read this form carefully and sign it to indicate that you understand and agree to the terms and conditions outlined below.

I have voluntarily elected to undergo this appointment after the nature and purpose has been explained to me, along with the risks and hazards involved by GET FUSED. By signing this form, I acknowledge that there are inherent risks involved with welding permanent jewelry. These risks include but are not limited to burns, discomfort, allergic reactions, and potential scarring, and I accept any such risks.

I agree to provide accurate and complete information about your health history, including any medical conditions, allergies, or medications that may affect your ability to undergo the welding process

By signing this form, I release GET FUSED and its employees from any liability for any harm, discomfort, or injury that may occur during the welding process. I also acknowledge that any injury or harm that results from the welding process is solely my responsibility.

In consideration of the permanent jewelry services to be performed by GET FUSED, I hereby release, indemnify, and hold harmless GET FUSED, its officers, directors, employees, agents, and affiliates from any and all claims, damages, losses, or expenses arising out of or in connection with the performance of permanent jewelry services.

I understand that this release covers all claims, including those based on negligence, breach of contract, or any other legal theory. I also acknowledge that I have read and fully understand this Liability Release Waiver, and that I am signing it voluntarily and without coercion.

I acknowledge that I am at least 18 years of age and that I have the legal capacity to enter into this Liability Release Waiver. If I am not 18 years of age, my parent or legal guardian has reviewed and signed this Liability Release Waiver on my behalf.

This Liability Release Waiver is binding upon me, my heirs, executors, administrators, and assigns.

I acknowledge that I have received and understand the aftercare instructions for the permanent jewelry, and agree to follow them as directed. 

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ALL THE INFORMATION IN THIS AGREEMENT AND I COMPLETELY UNDERSTAND IT BY SIGNING BELOW


CANCELLATION POLICY

Payment:Payment in full must be received on or before the first day of the appointment. A $25 deposit must be made Prior to your appointment. We offer the following payment options:

Cash or Check: We accept Cash, Checks, and Cashier's checks for payment for treatments. We all accept Cash App and Venmo. All returned checks will be assessed a return check charge of $30.00 each time a check is returned, regardless of the reason.

Credit Cards:We accept Visa, MasterCard, American Express and Discover.

Punctuality: Please arrive 15 minutes early so you can prepare for your appointment and enjoy the experience.

Arriving late: By arriving late, you will disrupt your appointment, reducing the time available for the appointment. If your more than 10 minutes late Your appointment will end and I will reschedule your appointment so there will be no disruption with the next appointment.

No show: We recommend that you get in touch with us and let us know if you will be late. No shows lead to the disengagement or voiding of any agreements you may have with our office.

Should you fail to arrive for your scheduled appointment without notifying us in advance on more than one occasion, your deposit or future appointments may be forfeited.

Cancellation: We adhere to a strict 48HR cancellation/rescheduling policy. In the event you fail to reschedule your appointment 48 hours prior to the initial appointment, cancel your appointment, or do not appear, you may forfeit your future appointments as well as any unused money or deposits.

If you cancel less than 48 hours before your scheduled appointment date, you will be charged 50% of the total fee. 

Date Signed: September 7, 2024


First Client's Name

First Name*

Last Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
First Client's Signature*
Second Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Third Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Fourth Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Fifth Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Sixth Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Seventh Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Eighth Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Ninth Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
Tenth Client's Name

First Name*

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

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
PERMANENT JEWELRY INFORMATION
Type of Jewelry
RING
ANKLET
BRACELET
NECKLACE
Type of Material
14K GOLD FILLED
.925 STERLING SILVER
14K SOLID GOLD/WHITE
HOW DID YOU HEAR ABOUT US?
Instagram
Facebook
Google
Local Business
Friend
Other

Other
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Client'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(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*
Parent or Guardian's Information

CONSULTATION FORM

PERSONAL INFORMATION


Date of Appointment:
Gender: *
M
F
O

HEALTH INFORMATION

Do you have any chronic medical conditions?*
No
Yes

If so please list
Do you have any Allergies?*
No
Yes
Are there any pre-existing skin conditions or scarring in the area where the welding will take place?*
No
Yes
Do you have Psoriasis, Eczema, or other inflammatory skin disorders?*
No
Yes
Do you have any Sensitivity or allergy to metals?*
No
Yes
Do you have Blood disorders ( hemophilia) ?*
No
Yes
Do you have any Photosensitivity ?*
No
Yes
Are you HIV positive?*
No
Yes
Do you have Epilepsy or Parkinson's disease?*
No
Yes
Do you have Lupus or Rheumatoid Arthritis?*
No
Yes
Are you currently (or possibly may be) Pregnant?*
No
Yes
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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