MINOR PIERCING RELEASE FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full name of the individual to be Pierced: *FirstLastPLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND EACH PROVISION AND THE IMPLICATIONS OF SIGNING THIS DOCUMENT. FEEL FREE TO ASK ANY QUESTIONS REGARDING THIS WAIVER.In consideration of receiving a Piercing from RAD INK including its artists, associates, apprentices, or any employees I agree to the following:I have been fully informed of the risks of body piercing including but not limited to infection and other medical complications, allergic reactions to metal jewelry, latex gloves, and antibiotics. Having been informed of the potential risks associated with receiving a body piercing, and I still wish to proceed with the procedure. I assume any and all risks that may arise from the body piercing. *I understand.RAD INK has given me the full opportunity to ask any question about the procedure and application of my piercing and all of my questions, if any, have been answered to my total satisfaction. *I understand.I have been given written aftercare instructions for the body piercing I am about to receive. *I understand.I have been informed about what I can expect following the body piercing including medical complications that may occur following this body piercing. *I understand.I understand that body piercing can result in nerve damage, bone and tooth loss, and that if I choose to remove my jewelry, permanent holes or scars may be left. *I understand.I am not pregnant or nursing. *I understand.I do not have a mental impairment that may affect my judgement in getting the Piercing. *I understand.I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventative regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing or piercing. *I understand.I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing without duress or coercion. *I understand.I understand there is a possibility of an allergic reaction to the jewelry inserted into the fresh body piercing. *I understand.I understand there is a possibility of getting an infection, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical attention. *I understand.I agree to follow all instructions concerning the care of my body piercing. *I understand. I understand that there is a chance I might feel lightheaded or dizzy during or after being pierced. *I understand.I agree to immediately notify the body piercer in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. *I understand.I agree that RAD INK has a NO REFUND policy on tattoos, piercing and/or retail sales and I will not ask for a refund for any reason whatsoever. *I understand. I am the person on the legal ID presented as proof that I am at least 18 years of age, or the body piercing will be performed in the presence of my parent or legal guardian. *I understand.I release the right to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form. (For assurance, if you do not check this provision, please inform RAD INK NOT to take any pictures of you and your completed piercing). *I understand.I WAIVE AND RELEASE to the fullest extent permitted by law any person of RAD INK from all liability whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my body piercing, whether caused by the negligence or fault of either RAD INK, or otherwise. *I understand.I agree to reimburse RAD INK for any attorneys' fees and costs incurred in any legal action I bring against RAD INK and in which either the Artist or the Body Piercing Studio is the prevailing party. I agree that the courts of located in the County of Brevard within the State of Florida shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any dispute arising out of or related to this agreement. *I understand.I acknowledge that I have been given adequate opportunity to read and understand this document that it was not presented to me at the last minute and grasp that I am signing a legal contract waiving certain rights to recover damages against RAD INK. *I understand. If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided valid proof of age and identification) and am competent to sign this Agreement. I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT. Signature * Clear Signature Printed Name *Today's Date *Date of Birth *Age *Current Address *Phone Number *Race *This is required by the health department – We hate that we have to ask this question.Gender *This is required by the health department – We hate that we have to ask this question.List of allergies: *Do you have a history of bleeding disorder: (if so, please explain) *Physicians Name *Physicians Address *Physicians Phone Number *Emergency Contact Name *Emergency Contact Address *Emergency Contact Phone Number * BELOW ITEMS TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN Name *FirstLastSignature * Clear Signature Date of birth *Date *Address *Race *This is required by the health department – We hate that we have to ask this question.Gender *This is required by the health department – We hate that we have to ask this question. BELOW TO BE COMPLETED BY PIERCER Part of the body being piercedDescription of jewelry being used for piercingNameSignature Clear Signature DateMinor form of identification Click or drag files to this area to upload. You can upload up to 5 files. Parent / Guardian form of identification Click or drag files to this area to upload. You can upload up to 5 files. Notarized form for minor Click or drag files to this area to upload. You can upload up to 5 files. PhoneSubmit
