Consent Form | Piinkparlor

First Name

Last Name

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Email

Phone

Address

Driver's License/I.D. Number

Date of Birth

Month

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I acknowledge by signing this consent form that i have been given the full opportunity to review it and ask any questions i have about obtaining body piercing services from Piink Parlor and all such questions have been answered to my full and total satisfaction. I agree to provide accurate information about the matters set forth below and I consent as follows:

PLEASE INITIAL TO INDICATE CONSENT TO EACH OF THE FOLLOWING. PARENT/LEGAL GUARDIAN PLEASE INITIAL ON BEHALF OF THE MINOR TO CONSENT TO EACH OF THE FOLLOWING REPRESENTATIONS ABOUT THE MINOR OBTAINING THE PIERCINGS.

I am neither pregnant nor nursing.

I acknowledge that if I am taking blood-thinning medications, antibiotics, am diabetic, or have a history of any other medical problems that ear or body piercing may carry a greater risk for me and I have consulted a physician before obtaining an ear or body piercing service from Piink Parlor.

I have advised Piink Parlor 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 the processes involved in the piercing and further acknowledge that such a reaction is possible.

I have faithfully represented to Piink Parlor that I am over the age of 18 years old or have a parent or legal guardian present if a minor. 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 aect my well-being as a direct or indirect result of my decision to have a piercing done at this time.

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-pierced condition.

I acknowledge that despite the piercer’s best eort and my proper after care, 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. I understand that aftercare is solely my responsibility and that Piink Parlor will not be able to monitor it.

I understand that I will be pierced with appropriate instruments, such as single-use, pre- sterilized solid needles.

I understand that fees for the ear or body piercing will not be filed with my insurance. All payments for this service are due in full at this time and no refunds are oered.

I agree to this ear or body piercing service with the understanding that ear and body piercing is a minor surgical procedure with similar risk to stitches or abscess drainage. I am fully aware that despite all precautions that are taken by Piink Parlor and my proper following of the aftercare instructions, the potential for infection exists. It is also possible that one of the following complications may occur as a result of obtaining ear or body piercing services:

Persistent Redness, Cellulitis, Swelling, Septicemia, Drainage, Keloids, Bleeding, Cauliflower Ear, Embedded/Clasped Earring, Pressure Sore, Local Infection, Scarring, Fainting, Allergic Reaction, Inflammation, Traumatic Injury.

Please seek immediate medical attention if you experience any of these symptoms.

I hereby assume all risks of loss or injuries of any kind associated with obtaining ear or body piercing services from Piink Parlor.

I hold only myself liable and hereby releases and waives all claims against Piink Parlor, its agents, or employees that I may make as a result of obtaining ear or body piercing services from Piink Parlor.

I have read and understand all the items listed above and agree to the terms. If the client is a minor , then the undersigned certifies to Piink Parlor that the undersigned is the parent or legal guardian to the minor client listed above.

Yes, subscribe me to your newsletter.

Signature

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If the client is a minor, relationship to client:

Minor's Name

Minor's Birthday

Month

Day

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I have observed a Piink Parlor piercer swtich to new disposable gloves for my piercing services.

I have observed a Piink Parlor piercer clean my piercing with a single-use disinfectant wipe before performing the piercing.

I have observed a Piink Parlor piercer use a single-use, pre-sterilized needle for my piercing.

Piercing Performed:

Which piercing was performed nostril, eyebrow etc.