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PIERCING CONSENT FORM


INFORMED CONSENT FORM

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please initial:

I hereby consent to and authorize the technician/esthetician to perform the following treatment/procedure: Piercing 


I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved. 


Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. 


I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. 


I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. 


I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense. 


I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes. 


I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, whose signature appears below, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today. 

Client Signature:

Date: July 24, 2025

I ACKNOWLEDGE THE FOLLOWING STATEMENTS:

  • I understand I am undergoing a piercing treatment. All piercing materials are single-use that are pre-packaged, sealed and sterilized.
  • If I am taking blood thinning medications or antibiotics, if I have diabetes, if I am pregnant or have a history of infection or any other medical condition, I acknowledge that the piercing may carry a risk and I must consult a physician for approval before piercings .
  • I understand that despite the best efforts of piercing artist and my own aftercare efforts, the potential for infection exists. Improper aftercare, poor hygiene, metal sensitivity or other causes, may increase the risk of infection. 
  • I understand that piercing may contribute to the formation of cysts or keloids.
  • I have read and understand the PIERCING AFTERCARE INSTRUCTIONS and I will receive a copy for my reference. 
  • I understand that Beauty Realm LLC., is unable to monitor my at-home aftercare, therefore it is my sole responsibility to follow the -PIERCING AFTERCARE INSTRUCTIONS provided at the time of piercing.
  • l have agreed to this piercing procedure and I am fully aware of the potential risks and complications. 

Initial here:


PIERCING RELEASE OF LIABILITY & CLAIM WAIVER

  • Beauty Realm LLC., and its Artist follow a safe and hygienic piercing protocol. However, improper core of newly pierced ears on my behalf or due to other causes can result in problems outside of their control. I, 'the undersigned, acknowledge that piercing carries some risks. These risks include but are not limited to infection, metal sensitivity, allergic reactions, inflammation, embedded earrings, scarring, fainting and other complications.
  • I understand that Beauty Realm LLC., and its body artist, when performing piercing procedures, do not act in the capacity of medical professionals. The recommendations made by the piercing specialist are recommendations only. They are not to be construed as, or taken as medical advice.
  • I voluntarily agree to this piercing procedure, for myself or for a minor in my care, and I am fully aware of the potential risks and complications. In addition, I hereby assume all risks of loss or injury of any kind whatsoever that may be associated with this piercing procedure.
  • By signing this PIERCING Release OF LIABILITY AND Claim WAIVER, I hereby acknowledge and represent the following:
  • I have read and understand this PIERCING RELEASE OF LIABILITY AND CLAIM WAIVER and sign it voluntarily.
  • I am at least I8 years old and hold myself liable in respect to this piercing procedure. I hereby release liability on behalf of Beauty Realm LLC., and their affiliates and waive any future claims against them.
  • I understand I must be 18 years old or older to have my ears and/or cartilage, nose, and naval pierced and my signature below confirms my acknowledgment. I realize this applies to first time piercings and consecutive piercings. I understand I must show proof of age by presenting some form of identification.
  • I am the parent or legal guardian of a minor under the age of I8 and hold myself liable in respect to this ear piercing procedure. I hereby release liability on behalf of Beauty Realm LLC., and their affiliates and waive any future claims against them.
  • For purposes of signing this PIERCING Release OF LIABILITY AND CLAIM WAIVER, I understand that it is fraudulent for a minor to represent herself/himself as an adult and/or to falsely represent oneself as a parent or legal guardian. 

Initial here:


PIERCING AFTERCARE INSTRUCTIONS AGREEMENT

I understand that I must carefully follow all PIERCING AFTERCARE INSTRUCTIONS and hereby release Beauty Realm LLC., and its Artists from any and all claims that I may have as a result of myfailure to follow all PIERCING AFTERCARE INSTRUCTIONS. 

Initial here:


EAR PIERCING AFTERCARE INSTRUCTIONS 

  • With clean hands, apply Aftercare Solution to the front & back of each piercing site Two -Three times per day. While cleansing, gently slide your earrings back & forth and rotate them in a circle only once. This will ensure absorption of the solution at the piercing site. For STUDEX Advanced Aftercare products, follow the instructions on the bottle. DO NOT REMOVE YOUR EARRINGS WHEN CLEANSING.
  • DO NOT TIGHTEN your earring backs.
  • Use care when using products like shampoo, soap, hair dye, perfume and hairspray near your ears. If possible, gently cover your piercing to avoid contact with these products. If contact occurs, rinse your ears immediately to avoid irritation.
  • Use care when styling your hair around your newly pierced ears. Brushes, combs, curling irons and hair dryers and even clothing should be kept a safe distance from your piercing. 
  • Use care while dressing. Pulling clothes over your head can result in trauma to your ears and slow the healing process.
  • Avoid swimming. If you must swim, cleanse your ears with aftercare products immediately.
  • Avoid over-the-ear headphones, hats, caps and scarves that rest at ear level.
  • For earlobe piercing, leave your new earrings in for SIX WEEKS. For cartilage piercing, leave your new earrings in for TWELVE WEEKS. After this time, provided your ears are completely healed, you may replace your earrings with another pair. DO NOT wear heavy earrings for at least 4 months to prevent stretching. If your ears begin to feel sore, return to your original earrings for 1-2 MORE WEEKS and resume the aftercare instructions.
  • Pain, redness and/or swelling are not normal reactions to ear piercing and are generally uncommon. Please consult a physician IMMEDIATELY. To reduce the risk of irritation, choose earrings that are made with surgical steel, 14 gold, titanium or stainless steel.  


Piercing Recipient Signature:

If you are under 18, the signature of a parent or legal guardian is required 

Date: July 24, 2025


POLICY CONSENT

Rescheduling & Cancellations

You are responsible for rescheduling or canceling your appointment via the booking app link sent to you by text. If you are experiencing technical issues, please text Jacky at 719-297-1447.

No charges for rescheduling if done 48 hours prior to your appointment time. 


Children Policy

To fully enjoy your experience, please leave children at home unless they are being serviced. Enjoy your self-care! 


Consent Forms

After your booking is confirmed, please visit the main page of my website and click the menu bar (top right-hand corner). Select the drop-down menu, proceed to select the consent form for your treatment. Forms must be completed at least 6-8 hours prior to your treatment time. 


Arrival Instructions

Upon arrival, find Jacky’s doorbell by the reception desk. Please have a seat and wait for your name to be called. You are welcome to use the restrooms within the facility. 


Conduct Policy

Disrespectful behavior will not be tolerated. You may be dropped as a future client if Jacky feels uncomfortable or unsafe. 


Tardiness

Appointments are subject to rescheduling and additional fees if you are more than 10 minutes late. 


Cancellation Fees

  • Late cancellation (less than 48 hours): 50% of service total
  • Same-day rescheduling/cancellation: 50% of service total
  • No-show/no-call: 100% of service total

No-shows or no-calls may result in being dropped as a future client. 


Refunds & Satisfaction Policy

Please note that no refunds will be issued for services rendered. However, your satisfaction is very important to me. If you are dissatisfied with your service, please contact me directly as soon as possible. I will work with you to address your concerns and ensure you are comfortable with your results. I am committed to providing an excellent experience and will make every effort to resolve any issues.


Retail Item Policy

All retail sales are final and non-refundable. However, if you are not completely satisfied with your purchase, I am happy to offer an even exchange for another product of equal value. Please contact Jacky within 7 days of purchase to initiate the exchange. Items must be unused, unopened, and in original condition to qualify for an exchange. 



Beauty Realm LLC
(719) 297-1447

First Client's Name
First Name*
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First Client's Date of Birth*
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First Client's Signature*
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Third Client's Name
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Fourth Client's Name
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Tenth Client's Name
First Name*
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Additional Information
Technician/Esthetician Performing Procedure:*
ID of Client or of Parent or Guardian (if Client is underage)
  
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Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*
Emergency Contact
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Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
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*
Middle 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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