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HIPPIE HOOPS AND HOLES PIERCING CONSENT

 

I acknowledge by signing this release I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing from Hippie Hoops and Holes LLC, and all my questions have been answered to my full and total satisfaction. I acknowledge I have been advised of the matters set forth below and I agree as follows:

Please Initial

- I am not pregnant. I will discuss with my piercer if I am breastfeeding. If I have any condition that might affect the healing of this piercing, I will inform my Piercer.

- 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 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 I am over the age of 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/or use of bodily function, and that no representation has been made to me as to the ability to later restore the skin/tissue/muscle involved in this piercing to its pre-piercing condition. Piercings can cause trauma and problems. I have done my research and decided to go forth with said piercing and will ask my piercer if I have any questions or concerns.

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

- I understand I will be pierced using appropriate instruments and sterilization

- I have eaten in the last 4 hours and will let my piercer know if I feel dizzy, lightheaded, or nauseated throughout the piercing process, even up to exiting the building.

- I understand this piercing may take up to a year to heal thoroughly. I agree to release and forever discharge and hold harmless the Piercer and all 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.

 March 3, 2024



First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
No
Yes
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*
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
I am choosing to purchase the necessary aftercare from HH&H to properly heal my piercing(s).*
No
Yes
I have been pierced by Hippie Hoops and Holes before.*
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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