Change Out/Insertion/Taper Release Form

First name

Last name

Piercing Service

i.e. jewelry insertion, change out, downsize, etc...

Phone

Address

Email

Pronouns

Preferred Name

Below please disclose any allergies or anything that may interfere with the procedure and/or healing process.

There is absolutely NO judgement for any disclosed information and is only asked so that we may provide you the safest experience!!

I affirm that I am free from bloodborne pathogens, communicable diseases, blood thinning medications and medical conditions that might affect the procedure and/or healing process (i.e. hemophilia, diabetes…)

YES

I am aware that inserting and/or changing body jewelry carries certain risks including but not limited to- infection, irritation and allergic reactions.

YES

If I am providing my own jewelry, I understand Pierced By Lucy (studio/piercer) does not assume any responsibility for the quality, material safety, sizing, sterilization or overall condition of jewelry not purchased from or provided by the studio.

YES

I understand that any damage that may occur to the jewelry I provide (breakage, scratching, deformation or inability to install) is not the responsibility of the studio or piercer.

YES

I affirm to waive and release to the fullest extent permitted by law each artist and the studio from all liability for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise...

YES

continued: including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the artist (Lucy Lovell) or piercing studio (Pierced By Lucy) or otherwise

I agree to reimburse the artist and piercing studio for any attorneys, fees and costs incurred in any legal action I bring against the artist or studio in which the artist or studio is the prevailing party. I agree that the courts of Virginia...

YES

continued: in the United States of America shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

Signature of Client

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Date

Month

Day

Year

Signature of Parent/Legal Guardian

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If client is under 18, if client is over 18 please use own signature again

Date

Month

Day

Year

PLEASE INCLUDE CLEAR, WELL LIT PHOTOS OF REQUIRED ID/IDS FRONT AND BACK

ID/IDs must be physically present at time of appointment

Change Out/Insertion/Taper Release Form *PLEASE COMPLETE PRIOR TO OR AT THE BEGINNING OF YOUR APPOINTMENT *PHYSICAL ID/IDS MUST BE PRESENT AT TIME OF APPOINTMENT *IF CLIENT IS UNDER 18, PARENT AND/OR LEGAL GUARDIAN MUST ACCOMPANY

Change Out/Insertion/Taper Release Form

PLEASE COMPLETE PRIOR TO OR AT THE BEGINNING OF YOUR APPOINTMENT
PHYSICAL ID/IDS MUST BE PRESENT AT TIME OF APPOINTMENT
*IF CLIENT IS UNDER 18, PARENT AND/OR LEGAL GUARDIAN MUST ACCOMPANY