Loading...

Piercing Procedure Waiver, Release & Consent



By signing below, I attest the following statements are true: 

I have provided accurate information on any medical conditions I may have or medications I may take that could adversely affect the outcome of this procedure, including but not limited to all allergies (e.g., iodine, nickel, latex, etc.), diabetes, anemia, hemophilia, high/low blood pressure, epilepsy, heart disease, immunosuppressive disorders, history of excessive swelling, medically diagnosed keloiding, or any condition requiring antibiotics prior to a medical procedure.  

I am at least 18 years of age, or if under 18 years of age, I am accompanied by my parent or legal guardian, and have proper documentation along with parental consent)

I am not currently under the influence of drugs or alcohol

I am of sound body and mind, and I agree to receive this piercing of my own free will, under no duress.

I am not currently pregnant or nursing a child. 

I am not currently experiencing any symptoms of acute illness, and to the best of my knowledge have not recently been exposed to anyone with any contagious illness. 

I acknowledge that in rare cases scarring, infection, keloid formation, muscle paralysis, nerve paralysis, allergic reaction, contact with blood borne diseases, excessive bleeding, and excessive swelling is possible, particularly in the event that I do not take proper care of my piercing. 

I agree to follow the written aftercare guidelines provided to me by Peterson MADE until my healing time is complete. I understand that the healing times listed on my aftercare sheet are only a guideline, and my piercing may take longer than stated to heal. 

I recognize that the suggestions and aftercare given to me by Peterson MADE's agents are based upon their education and experience in this field, along with current industry standards. Employees, contractors and agents of Peterson MADE are not doctors, therefore their suggestions, written or verbal, stated or implied, are not meant to be taken as medical advice. In the event of a serious medical concern, or by recommendation of my piercer, I will seek medical treatment by a licensed physician. 

I acknowledge that it is not reasonably possible for the piercer to determine if an allergic reaction is possible as a result of the jewelry used in my initial piercing. I accept the risk that such reaction is possible. 

I understand that all piercing jewelry sales are final. As soon as the jewelry has entered my body or left the studio, it is no longer sterile and is therefor unsafe to be used for anyone other than myself. 

I accept that after my piercer has opened single-use instruments and supplies for my procedure, if I choose to stop, postpone, or interfere with my piercing procedure, or if my piercer deems it unsafe or unprofessional to continue the service due to my health or behavior, I will be refunded ONLY for unused / uncontaminated jewelry / aftercare purchased during this visit, and my card on file will be charged for the service fee as payment for supplies and time. 

I agree to release and forever hold harmless Peterson MADE and the piercing professional from any and all claims, damages, or legal actions arising from or connecting in any way with my piercing and procedure, and/or conduct during the piercing process. I consent to the piercing procedure and the insertion of the jewelry and the actions or conduct of the piercer reasonably necessary to perform the piercing procedure.  

  

Signature

December 21, 2024



Please select who will be participating in the piercing procedure: ...
AdultMinor
Continue
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Gender*
Allergies
Antibiotics
Metals
Soaps
Latex
Alcohol
Petroleum
Diseases:
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV/AIDS
Herpes
Staph
Auto-Immunity
Asthma
Infections
Health Conditions:
Heart Disease
High Blood Pressure
Diabetes
Pregnant
Prone to Faintness
Skin Condition / Rash
Epilepsy
Hemophilia
prone to Scarring / Keloiding
Psoriasis
Blood Thinners
Eczema
Other: Please specify

If you have an Allergy / Disease / Condition not outlined above, please specify here:
Do we have your permission to photograph and use photos of your piercing on our social platforms, website, and promotions? I release any and all rights to any photographs taken of me and/or my piercing and give consent in advance to their reproduction in print and/or electronic form. If I do not wish to give consent, I recognize it is my responsibility to advise and remind my piercer they may not take any pictures of me and my piercing. *
Yes
No
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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:*
Upload a photo of your valid ID. Please note that Physical IDs *MUST* also be presented at the studio at the time of your appointment despite being uploaded digitally.
  
Upload an image of your valid photo identification *
Valid file types: JPG, GIF, PNG, and PDF

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.

**PHYSICAL COPIES OF STATE OR FEDERALLY ISSUED PHOTO IDENTIFICATION / ACCEPTABLE IDENTIFICATION MUST BE PRESENTED AT TIME OF APPOINTMENT** 

Failure to bring physical copies of the required identification / documents to your appointment will result in cancellation of your appointment, and your service fee will be charged to your card on file. 

If you are 18 years or older: you must have a state or federally issued photo ID, such as a drivers license, passport, military ID, or an ID issued by the DMV.

Minors 5 years – 17 years: acceptable identification includes a birth certificate + a school ID (presenting both), OR a passport, or state issued drivers license

A minor MUST have a Parent or Legal Guardian present at all times during the procedure. 

Note that parents / minors must have matching last names or addresses that match [on the IDs]. 

Legal Guardians must have a court order or letter of guardianship signed by a judge.  matching documentation. 

Acceptable documentations includes the following: 

Adults (18 years +) : A state or federally issued photo ID, such as a drivers license, passport, military ID, or an ID issued by the DMV.

Minors ( 5 years – 17 years): birth certificate + a school ID, OR a passport, or state issued drivers license

Legal Guardians: Photo ID & a court order or letter of guardianship signed by a judge.    


 



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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Gender*
Allergies
Antibiotics
Metals
Soaps
Latex
Alcohol
Petroleum
Diseases:
Hepatitis
Tuberculosis
Gonorrhea
Syphilis
HIV/AIDS
Herpes
Staph
Auto-Immunity
Asthma
Infections
Health Conditions:
Heart Disease
High Blood Pressure
Diabetes
Pregnant
Prone to Faintness
Skin Condition / Rash
Epilepsy
Hemophilia
prone to Scarring / Keloiding
Psoriasis
Blood Thinners
Eczema
Other: Please specify

If you have an Allergy / Disease / Condition not outlined above, please specify here:
Do we have your permission to photograph and use photos of your piercing on our social platforms, website, and promotions? I release any and all rights to any photographs taken of me and/or my piercing and give consent in advance to their reproduction in print and/or electronic form. If I do not wish to give consent, I recognize it is my responsibility to advise and remind my piercer they may not take any pictures of me and my piercing. *
Yes
No
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!