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Piercing Release

Piercing Release Form

I ____ allow for ______ to be pierced and in considerations of it doing so, I hereby release _____ and its employees and agents, from all liability by reason of complying with my request to be pierced. I FULLY UNDERSTAND THAT ANY EMPLOYEE or agent of _____ , when performing body piercing, does not act in the capacity of a medical professional. The suggestions made by any employee or agent of _______ are just suggestions. They are not to be construed as or substituted for advice from a medical professional.


I UNDERSTAND MY ______ 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.

MY _____ AND I HAVE RECEIVED A COPY OF THE “AFTERCARE INSTRUCTIONS” SHEET, which we have read and fully understand and hereby assume full responsibility for aftercare and cleanliness for my ____ . I understand that by having this piercing performed my ______ is making a permanent change to _____ body and no claims have been made regarding the ability to undo the changes made.

BY MY SIGNATURE BELOW, I certify that I am the _____ of _____ , who is at least ____ years old, and also willingly submits to these procedures, with a full understanding of complications such as but not limited to infection, allergic reaction, or rejection of the piercing.

Please answer the following questions so that we may serve you better:

Have you eaten within the last 4 hours?
Have you had any alcoholic beverages within the last 8 hours?
Are you prone to fainting?
Are prone to heavy bleeding?
Have you taken aspirin, ibuprofen or anticoagulants within the last 24 hours?
Do you have any allergies? If yes, explain
Do you have any conditions which might affect the healing of this piercing? If yes, explain
Are you pregnant?

Thanks for submitting!

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