Body Piercing Release Form

Body Piercing Release Form

I acknowledge by signing this agreement that I have read this document and been given the full opportunity to ask any and all questions I might have about the obtaining of this procedure from the staff of Salvation tattoo lounge and that all of my questions have been answered to my full satisfaction, and have been advised of the facts set forth below, and I agree as follows: I do not have diabetes, epilepsy, hemophilia, a heart condition, hypoglycemia, high blood pressure, low blood pressure, or take any medicine which thins the blood. I do not have any infectious diseases such as, but not limited to, hepatitis, HIV, aids, tuberculosis, or any other communicable diseases. I have not had jaundice or hepatitis within the last two years. I am not pregnant or nursing. I do not have any medical condition that may place myself or the representatives of Salvation tattoo lounge at risk during the course of the procedure to be performed. I understand that if I misrepresent any medical condition that may place the owner or representatives of Salvation tattoo lounge at risk I may be held liable to the fullest extent of the law. I am not under the influence of drugs or alcohol. I do not have any medical or skin conditions such as, but not limited to acne scarring (keloid), exome, psoriasis, freckles, moles, or sun burn in the area to be worked on during this procedure which may interfere with the procedure. I acknowledge that I am not allergic to iodine or latex and that it is not reasonably possible for the representative of Salvation tattoo lounge to determine such. I may have a reaction to the equipment or process used in this procedure. I agree to accept the risk that such a reaction is possible. I acknowledge that infection is always possible as a result of obtaining this procedure, and I agree that I will follow all instructions concerning the care of the affected area during the healing process. I have been given these instructions and will follow them. I agree that any follow up work needed due to my own negligence will be done at my own expense. I acknowledge the potential risks of disfigurement associated with these procedures. I do not have any physical, mental, medical impairment, or disability which might affect my well-being as a direct or indirect result of the decision to have this procedure done at this time. I consent to the procedure and to any actions or conduct of the owner of contractors of Salvation tattoo lounge reasonably necessary to perform the procedure. I release all rights to any photographs taken and give complete advance consent  forany reproductions in any print or electronic form or exhibition in any venue. I acknowledge that there is no legal reason that precludes me from giving my consent for the procedure to be performed. I understand the risks and consequences associated with the Body Piercing procedure including but not limited to bleeding, bruising, swelling, irritation, pain, or scarring. I agree to release and hold harmless Salvation tattoo lounge, its owner, and representatives from any and all claims, damages, rights, demands or legal actions arising from on connected in any way to the procedure and conduct used to obtain this procedure. I forfeit my right as well as the rights of any heirs or states to seek compensation from any injuries, damages, or death resulting from my decision to undergo this procedure whether or not caused by negligence. In the event of any litigation arising from or relating to this agreement or the services provided to me under this agreement Salvation tattoo lounge shall be entitled to recover all reasonable costs incurred including staff time, court costs, attorney’s fees, and all other related expenses from the non-prevailing party if Salvation tattoo lounge is the prevailing party. I agree to leave the premises of Salvation tattoo lounge promptly upon request for any reason whatsoever. I understand that Salvation tattoo lounge reserves the right to refuse anyone for any reason. Additionally, Salvation tattoo lounge reserves the right to decline to perform certain procedure on any individual at the discretion of the artist on duty.

PLEASE COMPLETE IN FULL I have reviewed and agree to the policies and requirements of Salvation Tattoo Lounge, and hereby give consent to Salvation tattoo lounge to perform the procedures I have requested. I have received verbally and in writing all the aftercare instructions and agree to follow those instructions. The establishment must obtain a written notarized consent statement before piercing a minor. If the minor is under the age of 16, the minor also must be accompanied by a parent or legal guardian 

    TO BE COMPLETED BY MANAGER ON DUTY

    TO BE SIGNED BY CUSTOMER BEFORE THE REQUESTED PROCEDURE

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