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PIERCING RELEASE
To Induce __________
To pierce my _______
I hereby release Naked Face Spa Cosmetic and its employees and agents, from all manner of ,claims, actions and demands, in law or in equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to be pierced. I FULLY UNDERSTAND THAT ANY EMPLOYEE or agent of Naked Face Spa Cosmetic, when performing body piercing, does not act in the capacity of a medical professional. The suggestions made by any employee or agent of Naked Face Spa Cosmetic are just suggestions. They are not to be construed as or Substituted for advice from a medical professional.
I UNDERSTAND I WILL BE PIERCED using appropriate instruments and techniques. To ensure proper healing of my piercing, I agree to follow the aftercare procedures outlined in the 'Aftercare Instructions sheet, until healing is complete. I understand that this type of piercing usually takes ______, or longer to heal.
I WILLINGLY SUBMIT TO THESE PROCEDURES, with a full understanding of possible complications such as but not limited to infection, allergic reaction, or rejection of the piercing.
I HAVE RECEIVED A COPY OF THE "AFTERCARE INSTRUCTIONS" SHEET, which I have read and fully understand and hereby assume full responsibility for aftercare and cleanliness. I understand that by having this piercing performed I am making a permanent change to my body and no claims have been made regarding the ability to undo the changes made.
Please Answer The Following Questions So That We May Serve You Better
Have you eaten with the last 4 hours?
Yes
No
Have you have any alcoholic beverages in the last 8 hours?
Yes
No
Are you prone to fainting?
Yes
No
Are you prone to heavy bleeding?
Yes
No
Have you taken aspirin, ibuprofen or anticoagulants with in the last 24 hours?
Yes
No
you have any allergies?
Yes
No
If yes, what?
Are you pregnant?
Yes
No
Do you have any conditions which might affect the healing of this piercing?
Yes
No
If yes, what?
How did you hear about
Friend/ Relative
Repeat Customer
Other
Name
Address
Email
City , State , & Zip
By my :signature below I efflift that I am 18 years of age or older. further understand that give false information or produce false documents stating my name and age to be other than correct,. then I am liable for prosecution.
Your Signature
Clear
Date
Age
Photo ID/Type
Jewelry Inserted
Fee $
Jewelry$
Salt$
Satin$
Date of Birth
Comments
Tech 2000 $
I acknowledge that the sterilization procedures used were explained to my full satisfaction and Iliad the opportunity to ask any question regarding these procedures. Both written and verbal aftercare instructions were provided to me.
Piercer Initials
Client Initials:
Day of Week
Time of Day
Submit
Thanks for submitting!
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