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Consent & Release Form

 

I acknowledge by signing this Release I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing from Pretty Pain by Peri and all my questions have been answered to my full and total satisfaction. I acknowledge I have been advised of the matters set forth below and I agree as follows:

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  1.  I am not pregnant or nursing. If I have any condition that might affect the healing of this piercing, I will inform my piercer.

  2. I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.

  3. I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.

  4. I have trustfully represented to the Piercer I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.

  5.  I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition.

  6. I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and I agree to follow all of them while my piercing is healing.

  7. I understand I will be pierced using appropriate instruments and sterilization.

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**By signing and the answering the following questions, I agree to the above terms**

Please Answer the Following Questions:

*Answering "yes" to any of these questions does not necessarily preclude the person from receiving a tattoo or piercing.

Has a physician told you that you have hepatitis? Have you been jaundice (yellowing of skin or eyes) in the previous 10 days?
YES
NO
Are you prone to fainting?
YES
NO
Do you have diabetes?
YES
NO
Do you have difficulty-stopping bleeding?
YES
NO
Do you take a blood thinner?
YES
NO
Do you have heart related problems?
YES
NO
Do you have high blood pressure?
YES
NO
Do you have any known allergies?
YES
NO
Have you consumed any alcoholic beverages within the last 8 hours?
YES
NO
Have you consumed any food within the last 2 hours?
YES
NO
Have you consumed any anticoagulants (aspirin, ibuprofen, etc.) in the last 24 hours?
YES
NO
Are you pregnant?
YES
NO
Do you have any other conditions that might affect the healing of this tattoo/body piercing?
YES
NO
Date of Birth
Date
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