Piercing Release Form

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Practitioner *

Type of Piercing

Contents of Cycle *

Additional Information

File Upload *

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WAIVER, RELEASE, AND CONSENT TO BODY PIERCING

PLEASE READ AND BE CERTAIN THAT YOU UNDERSTAND AND AGREE TO THE IMPLICATIONS OF SIGNING THIS DOCUMENT.
PLEASE READ CAREFULLY AND THEN INITIAL NEXT TO EACH PROVISION TO SHOW THAT YOU UNDERSTAND AND AGREE TO WHAT IS WRITTEN.

Please initial in all of the spaces provided

By initialling you show that you have read and understand all of the provisions below

I hereby give consent to AVA Piercing Company to perform a body piercing, and in consideration of doing so, I hereby release both my piercer and AVA Piercing Company from all manner of liabilities, claims, actions, and demands in law, or in equity, which I or my heirs might now or hereafter by reason of complying with my request of a body piercing. *

Please initial above

I fully understand that any employee of AVA Piercing Company, when performing a body piercing, does not act as a medical professional. Any instructions or suggestions I receive by any employee or agent of AVA Piercing Company should not be considered a substitute for advice from a medical professional. *

Please initial above

I fully understand that the body piercing I receive from AVA Piercing Company will be performed using appropriate techniques and instruments. I have been given ample opportunity to ask questions about these techniques and instruments. I feel that all my questions have been answered to my satisfaction. *

Please initial above

I have been given both verbal and written instructions regarding the cleaning and aftercare suggested by AVA Piercing Company. I fully understand these instructions and agree to follow them. I understand that all piercings may become infected, inflamed, or irritated due to lack of proper hygiene, negligence, or other circumstances. *

Please initial above

I understand that I am making a permanent change to my body and there have been no claims made by my piercer or AVA Piercing Company that these changes are reversible. I may be left with a scar or other change even if the piercing is removed. I understand that body piercings may take several months to heal and I am responsible for proper aftercare throughout the duration of the healing period. Knowing the inherent risks associated with body piercings, I still wish to proceed with a body piercing. *

Please initial above

I am not under the influence of drugs or alcohol. I am getting this piercing voluntarily and without duress. *

Please initial above

I do not have any skin conditions or medical conditions that may interfere with the healing process nor the piercing procedure. *

Please initial above

I am not the recipient of an organ or bone marrow transplant, or, if I am, I have taken the prescribed preventative regiment of antibiotics that is required by my doctor in advance of any invasive procedure such as a piercing. *

Please initial above

I understand that for health and safety reasons, all sales are final. Jewelry cannot be returned or exchanged under any circumstances. *

Please initial above

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

Please initial above. If you prefer not to have photos of your piercings taken, please leave this blank.

I agree to reimburse Ava Piercing Company along with its piercers and employees for any attorney fees and costs incurred in any legal action I bring against the studio or employees in which Ava Piercing Company or its piercers or employees is the prevailing party. I agree that the courts of Riverside County in California 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. *

Please initial above

I acknowledge and understand that I am signing a legal contract that waives certain rights to recover against Ava Piercing Company along with its piercers and employees. *

Please initial above

I acknowledge that I have been given ample opportunity to read and understand this entire document and that it was not provided to me last minute. *

Please initial above

I understand that all jewelry used at Ava Piercing Company is covered by a manufacturer’s warranty only and that the warranty does not extend to jewelry that I have lost or damaged due to my own negligence. Ava Piercing Company and its piercers and employees are not responsible for replacing jewelry that I have lost or damaged and I must purchase any jewelry that needs replaced after I have lost it. *

Please initial above

PLEASE READ CAREFULLY BELOW AND ANSWER YES OR NO TO THE FOLLOWING QUESTIONNAIRE AND PROVIDE DETAILS WHEN NECESSARY.

I am pregnant or nursing *

We cannot pierce anyone who is pregnant or nursing.

I have a history of herpes infection at the proposed procedure site *

I have diabetes *

I have an allergy to latex or antibiotics. *

We do not use latex gloves for any procedure.

I have hemophilia, other bleeding disorder, or cardiac valve disease. *

I have a history of medication use. *

I am currently on prescribed medication or am prescribed antibiotics prior to dental or surgical procedures. *

Are there any other risk factors for blood borne exposure? *

In the past 24 hours, have you felt any flu like symptoms (fever, sore throat, coughing, etc)? *

Have you eaten today? *

If there is anything you need us to know before getting pierced, let us know here!

We're happy to make whatever accommodations we can! Please let one of our staff know if we need to pay extra close attention to this section. If you need us to keep this discrete, please input that into the notes and we'll make sure to use extra caution.

If there is any provision, section, subsection, clause, or phrase of this release that is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be reconstructed as though the unenforceable portion had never been contained in this document.

I hereby declare that I am of legal age, have provided valid proof of my age, and am competent to sign this agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

Legal Name *

First

Last

Layout

What name would you like us to call you?

Email *

Date of Birth *

Pronouns

Phone Number *

Age *

Today's Date *

Signature *

If you are under the age of 18, you will sign here and your parent/guardian will sign below. If you are over the age of 18, sign here. You will not need to sign in the second signature box.

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How did you hear about us?

The Association of Professional Piercers (safepiercing.org)
Internet Search
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I was referred by someone!

Let us handle this part!

WAIVER, RELEASE, AND CONSENT TO BODY PIERCING

Please initial in all of the spaces provided

PLEASE READ CAREFULLY BELOW AND ANSWER YES OR NO TO THE FOLLOWING QUESTIONNAIRE AND PROVIDE DETAILS WHEN NECESSARY.

Please go ask one of our staff for a snack ☺️

I hereby declare that I am of legal age, have provided valid proof of my age, and am competent to sign this agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

Guardian/Parent Information

Like this:

Let us handle this part!

WAIVER, RELEASE, AND CONSENT TO BODY PIERCING

Please initial in all of the spaces provided

PLEASE READ CAREFULLY BELOW AND ANSWER YES OR NO TO THE FOLLOWING QUESTIONNAIRE AND PROVIDE DETAILS WHEN NECESSARY.

Please go ask one of our staff for a snack ☺️

I hereby declare that I am of legal age, have provided valid proof of my age, and am competent to sign this agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

Guardian/Parent Information

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