Piercing Release Form

Black Cloud Tattoo & Piercing CONSENT TO PIERCE & RELEASE OF ANY CLAIMS.

I acknowledge by signing this Release that I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing or jewelry change from the Piercing Tech present at Black Cloud Piercing and Body Jewelry and all my questions have been answered by the staff/associates of this establishment.

Store Location:*

Phone Number*

Full Name*

Date of Birth:*

Address (Street, City, State, Zip Code)*

* I have been advised the Piercer of any allergies to metals, latex gloves, soaps and solutions. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the jewelry or disposables involved in the piercing and further acknowledge that such a reaction is possible. If any signs of allergies arise later I will consult with my physician and/or remove my jewelry. I have been provided with all information describing the body piercing procedure to be performed. I acknowledge that receiving services/piercing is my choice alone and I have consulted with my physician prior to receiving any piercing/service to assure my health. I acknowledge a piercing is a perforation and will result in a permanent change in appearance, and that no representation has been made to me as to the ability to restore the skin involved in this piercing to is pre-piercing condition. I am not pregnant or nursing. If I have any condition that might affect the healing of this piercing, I will inform the piercer. 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. I do not have epilepsy, AIDS, HIV; I do not have hepatitis, or other contagious medical conditions; I am not a hemophiliac (bleeder) and I do not take blood thinners; I do not have a heart condition.I understand I will be pierced using appropriate single use needles, disposables, surgical stainless steel 316L medical grade instruments and that the establishment is enrolled in a periodically endo-spore testing and acquired certificates with an unbiased laboratory. The piercer has been adequately trained by professionals and acquired certificates from blood borne pathogen institutes and other first aid care programs. We Do Not Pierce with a piercing gun for sanitary and health reasons.I agree to release and forever discharge and hold harmless the Piercer and all staff of Strategic Venture Solutions Inc. dba Black Cloud Piercing and Body Jewelry from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing. I agree to pay for any and all damages, court cost, attorney representing Strategic Venture Solutions Inc. or injuries to any and all persons and property of SVS, Inc. belonging to SVS, Inc., or any other person to whom SVS, Inc. and representatives may become liable contractually or by operation of law, caused by, or resulting from my decision to have any piercing-related work done by a representative of SVS, Inc.I have truthfully represented to Black Cloud Piercing and Body Jewelry and its associates I am over the age of 18 years . I attest that I am not using a false Identification to receive services or representing myself as someone else. 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. I have read and understood each of the above paragraphs and I have been given a chance to translate this release form in any language or form of my understanding. I understand all aftercare instructions given to me verbal and/or in written form. Therefore I release Black Cloud Tattoo and Piercing (SVS, Inc.) from all if any claim that may result from my own care of my piercing/service.

Todays Date*

Your Electronic Signature*