Piercing Release Form

First name

Last name

Pronouns

Preferred Name

Piercing Service

Please list the piercing service you are receiving (i.e. earlobe piercing, nostril downsize, jewelry change out...)

Phone

Address

Email

In the past 48 hours have you experienced any of the following: fever, flu like symptoms, cough/shortness of breath

If answering YES please specify

Have you eaten within the past 4 hours?

YES

NO

It is recommended to eat before your appointment and stay well hydrated prior to and after your appointment

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 acknowledge that the piercing will result in a permanent change to my appearance and that my skin may not be restored to its pre-piercing condition even after its removal.

YES

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.

YES

I affirm that I am not pregnant or nursing.

YES

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 acknowledge that I have been fully informed of the risks associated with getting a piercing. Having been informed of the potential risks, I still wish to proceed with the piercing and I freely accept all risks that may arise.

YES

Risks include but are not limited to: infection, scarring, allergic reaction

I affirm to waive and release to the fullest extent permitted by law each of the Artist (Lucy Lovell) and the Piercing Studio (Pierced By Lucy LLC) from all liability

YES

continued: for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, 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 the Piercing Studio (Pierced By Lucy LLC), or otherwise.

I agree to reimburse the Artist (Lucy Lovell) and the Piercing Studio (Pierced By Lucy LLC) for any attorneys, fees and costs incurred in any legal action I bring against either the Artist or the Piercing Studio...

YES

CONTINUED: ...is the prevailing party. I agree that the courts of Virginia 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.

I release all rights to any photographs taken of me and the piercing or service received and give consent in advance to their reproduction in print or electronic form.

YES

NO

6. I affirm that that both the Artist (Lucy Lovell) and the Piercing Studio (Pierced By Lucy LLC) have given me the full opportunity to ask any and all questions about the piercing procedure and my questions have been answered to my total satisfaction.

YES

I affirm that I have been given aftercare instructions and I understand these instructions and will follow them. I acknowledge that it is possible that the piercing can become irritated or infected, particularly if I do not follow these instructions.

YES

Aftercare sheets are available for all clients and through the APP website. Specific aftercare routines will be discussed at the time of your appointment

I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.

YES

Signature of Client

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Date

Month

Day

Year

Signature of Client's Parent/Legal Guardian (If under 18) IF OVER 18 PLEASE USE YOUR OWN SIGNATURE AGAIN

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Date

Month

Day

Year

PLEASE UPLOAD CLEAR, WELL LIT PHOTOS OF YOUR ID/IDS (FRONT AND BACK) IDS MUST BE PHYSICIALLY PRESENT AT THE TIME OF YOUR APPOINTMENT