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.
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, Body Piercing may involve possible health risks. These risks may include: Pain, bleeding,
swelling, infection, hypertrophic scarring, scarring of the area, febrile illness, tetanus, systemic infection, 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. 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.
HEALTH HISTORY AND INFORMED CONSENT
The following conditions may increase health risks associated with receiving body art:
- diabetes
- hemophilia (bleeding)
- skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.
- history of allergies or adverse reactions to pigments, dyes, or other sensitivities
- history of epilepsy, seizures, fainting, or narcolepsy;
- use of medications such as anticoagulants. (such as coumadin) which thin the blood and/or interfere with blood clotting; and
- 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: 978-462-3430
CLIENT CONFIRMATION
I have received the above information; I do not have a condition that prevents me from receiving body art. I consent to the performance of the body art procedure and will be provided written and verbal aftercare instructions.
* Signature Below *
Provide Signature By Drawing
In Box With Finger
