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BODY PIERCING CONSENT FORM

I have been fully informed of the BODY PIERCING RELEASE FORM: inherent risks associated with getting a piercing. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring and keloids, allergic reaction to jewelry, latex gloves, and/or soap. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing, and I freely accept and expressly assume any and all risks that may arise from piecing.




By signing this form I agree to the following:

I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute. I do not have a mental or physical impairment which may affect my judgment or well being, as a direct or indirect result of my decision to have a piercing performed. That the piercer, the studio, nor any of it’s employees should be held responsiblein any claims, damages, actions, judgments, cost of litigation, attorney’s fee’s, nor other cost expenses that may arise from my decision to have a piercing performed at this time. By signing this form, I release all rights to any photographs/videos taken of me and the piercing and give consent in advance to their reproduction in prints and social media.


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BOARD OF HEALTH - BODY ART DISCLOSURE STATEMENTS

THIS STATEMENT IS TO BE GIVEN TO ALL BODY ART CLIENTS, AND IS TO BE SIGNED BY THE CLIENT, PRIOR TO PERFORMING ANY BODY ART PROCEDURE

BODY PIERCING DISCLOSURE STATEMENT

As with any invasive procedure, tattooing may involve possible health risks. These risks may include: Pain, bleeding, swelling, infection scarring of the area, and nerve damage.

THE BODY ART PRACTITIONER SHOULD

Properly and thoroughly clean the area before the procedure. Use ONLY sterilized equipment. Use ONLY sterile techniques. Provide information on the aftercare of the area receiving body piercings. Pain, bleeding, swelling, infection scarring of the area, and nerve damage Un-sterile equipment and needles can spread infectious diseases; it is extremely important to be sure that all equipment is clean and sanitary before a use. Tattoos and permanent makeup are not easily removed and, in some cases, may cause permanent discoloration: think carefully before getting a tattoo. The is also the possibility of an allergic reaction. The inks or dyes used for tattoos are color additives. Currently, no color additives have been approved by FDA for tattoos, including those used in permanent make up Blood donations cannot be made for a year after getting a tattoo or permanent makeup.

HEALTH HISTORY AND INFORMED CONSENT

The following conditions may increase health risks associated with receiving body art:

  1. diabetes
  2. hemophilia (bleeding)
  3. skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.
  4. history of allergies or adverse reactions to pigments, dyes, or other sensitivities
  5. history of epilepsy, seizures, fainting, or narcolepsy;
  6. use of medications such as anticoagulants. (such as coumadin) which thin the blood and/or interfere with blood clotting; and
  7. hepatitis or HIV infection

PROCEDURE FOR FILING A COMPLAINT

If there is any injury, infection,complication or disease as a result of a body art procedure notify this establishment and the following local board of health at Salisbury Health Dept., 5 Beach Road, Salisbury, Massachusetts 01952.

Phone # 1-978-462-3430