𝕭𝖑𝖆𝖈𝖐 𝕺𝖓𝖞𝖝 𝕰𝖒𝖕𝖎𝖗𝖊 𝕿𝖆𝖙𝖙𝖔𝖔
Piercing
Piercing Waiver Form
Piercing Minor Waiver Form
Piercing Infant Waiver Form
Tattoo
Tattoo Waiver Form
Tattoo Minor Waiver Form
Tattoo Apprentice
>
Apprentice Tattoo Waiver Form
Apprentice Tattoo Minor Waiver Form
Products
Esthetics
Piercing Waiver
*Stop!*
This Section to be filled out by a Staff Member.
*
Indicates required field
Copy of ID (Ensure the client is at least 18)
*
Max file size: 20MB
Staff Member
*
Onyx
Sosa
Peach
Guest Piercer
Procedure
*
Piercing
Jewelry Change
Piercing Removal
Body Modification
Piercing/Procedure Description (Be specific)
*
Body Location (Question Marks void your liability protection)
*
Procedure Cost (USD)
*
Does the Client have a Coupon/Gift Card? (If unsure, ASK)
*
Yes
No
Client Section:
Legal First and Last Name
*
First
Last
Date of Birth (MM/DD/YYYY)
*
Phone Number (111)111-1111
*
Waiver: PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING. In consideration of receiving a piercing from (the “Piercer”) and (Black Onyx Empire, hereafter referred to as "The Company"), (and its employees, apprentices and agents, here and after collectively referred to as “the Piercing Studio”), I agree to the following: I,the mentioned client, have been fully informed of the inherent risks, associated with getting a piercing. I, the undersigned, hereby certify that I am aware that there are risks inherent in ear piercing. I understand that ear piercing is a minor surgical procedure with similar risks to stitches or abscess drainage. Despite all precautions that are taken by the Piercer and proper following of aftercare instructions, the potential for infection still exists. There is also the potential that any of the following complications may occur as a result of ear piercing: persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, cellulitis, blood poisoning (septicemia), keloid formation, cauliflower ear, pressure sore or traumatic injury. **Please contact us if any of these symptoms are experienced. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing application and I freely accept and expressly assume any and all risks that may arise from the piercing. I WAIVE AND RELEASE to the fullest extent permitted by law each of the Piercer and The Company from all liability whatsoever, 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 from the application of my piercing, whether caused by the negligence or fault of either the Piercer or The Company, or otherwise. Both the Piercer and The Company have given me the full opportunity to ask any and all questions about the application of my piercing and all of my questions have been answered to my total satisfaction. The Piercer and The Company have given me instructions on the care of my piercing while it’s healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. If any follow up work to the piercing is needed due to my own negligence, I agree that the work will be done at my own expense. I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be pierced by the Piercer without duress or coercion. I do not not have diabetes, epilepsy, hemophilia, a heart condition, nor do they take blood thinning medication. I do not have any other medical or skin condition that may interfere with the application or healing of the piercing. I am not the recipient of an organ or bone marrow transplant or, if they are, they have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as piercing. I do not have a mental impairment that may affect our judgment in getting the piercing. Neither the Piercer nor The Company is responsible for the placements provided for them to choose from. A piercing is a permanent change to the my appearance and in some occasions only be removed by surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of their skin to its exact appearance before being pierced. I release all rights to any photographs taken of the minor and the piercing and give consent in advance to their reproduction in print or electronic form. (If you do not check this provision, please advise and remind your Piercer and The Company NOT to take any pictures of you and your completed piercing!). I agree to reimburse each of the Piercers and The Company for any attorneys’ fees and costs incurred in any legal action I bring against either the Piercer or The Company and in which either the Piercer or The Company is the prevailing party. I agree that the that the courts of the designated City and State 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 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 waiving certain rights to recover against the Piercer and The Company.
Waiver:
*
I agree.
PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING. In consideration of receiving a piercing from (the “Piercer”) and (Black Onyx Empire, hereafter referred to as "The Company"), (and its employees, apprentices and agents, here and after collectively referred to as “the Piercing Studio”), I agree to the following: I,the mentioned client, have been fully informed of the inherent risks, associated with getting a piercing. I, the undersigned, hereby certify that I am aware that there are risks inherent in ear piercing. I understand that ear piercing is a minor surgical procedure with similar risks to stitches or abscess drainage. Despite all precautions that are taken by the Piercer and proper following of aftercare instructions, the potential for infection still exists. There is also the potential that any of the following complications may occur as a result of ear piercing: persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, cellulitis, blood poisoning (septicemia), keloid formation, cauliflower ear, pressure sore or traumatic injury. **Please contact us if any of these symptoms are experienced. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing application and I freely accept and expressly assume any and all risks that may arise from the piercing. I WAIVE AND RELEASE to the fullest extent permitted by law each of the Piercer and The Company from all liability whatsoever, 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 from the application of my piercing, whether caused by the negligence or fault of either the Piercer or The Company, or otherwise. Both the Piercer and The Company have given me the full opportunity to ask any and all questions about the application of my piercing and all of my questions have been answered to my total satisfaction. The Piercer and The Company have given me instructions on the care of my piercing while it’s healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. If any follow up work to the piercing is needed due to my own negligence, I agree that the work will be done at my own expense. I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be pierced by the Piercer without duress or coercion. I do not not have diabetes, epilepsy, hemophilia, a heart condition, nor do they take blood thinning medication. I do not have any other medical or skin condition that may interfere with the application or healing of the piercing. I am not the recipient of an organ or bone marrow transplant or, if they are, they have taken the prescribed preventive regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as piercing. I do not have a mental impairment that may affect our judgment in getting the piercing. Neither the Piercer nor The Company is responsible for the placements provided for them to choose from. A piercing is a permanent change to the my appearance and in some occasions only be removed by surgical means, which can be disfiguring and/or costly and which in all likelihood will not result in the restoration of their skin to its exact appearance before being pierced. I release all rights to any photographs taken of the minor and the piercing and give consent in advance to their reproduction in print or electronic form. (If you do not check this provision, please advise and remind your Piercer and The Company NOT to take any pictures of you and your completed piercing!). I agree to reimburse each of the Piercers and The Company for any attorneys’ fees and costs incurred in any legal action I bring against either the Piercer or The Company and in which either the Piercer or The Company is the prevailing party. I agree that the that the courts of the designated City and State 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 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 waiving certain rights to recover against the Piercer and The Company.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement.
Compliance:
*
I comply.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign this Agreement.
Please check if you have ANY of the following conditions AND INFORM A STAFF MEMBER IMMEDIATELY
*
CARDIAC VALVE DISEASE
BLEEDING DISORDER
DIABETES
TUBERCULOSIS
SCARRING
EPILEPSY
ASTHMA
HEART CONDITION
PREGNANT/NURSING
HEMOPHILIA
HERPES
BLOOD THINNERS
SKIN CONDITION
FAINTING/DIZZINESS/VERTIGO
HIV/AIDS
I DO NOT HAVE ANY OF THE ABOVE LISTED MEDICAL CONDITIONS OR ANY OTHER CONDITIONS THAT WILL AFFECT MY PROCEDURE AND HEALING.
eSignature
The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Please Type Your Legal First and Last Name
*
First
Last
[object Object]
Click to Confirm Compliance to this eDocumen
Piercing
Piercing Waiver Form
Piercing Minor Waiver Form
Piercing Infant Waiver Form
Tattoo
Tattoo Waiver Form
Tattoo Minor Waiver Form
Tattoo Apprentice
>
Apprentice Tattoo Waiver Form
Apprentice Tattoo Minor Waiver Form
Products
Esthetics