Release Form
Ask a staff member what to enter
Today's Date:
Fri Apr 26 2024 06:40
Practitioner:
*
-- Select --
Anyone
Release/Consent Form
Please read and answer
BBP
*
Do you have any Blood Borne Pathogen that we need to be aware of for safety? Transmittable disease? Recent Illness?
Risks
*
I am fully aware of the risks associated with Body Piercing. Risks included can lead to injury, including but not limited to infection, scarring, keloiding and allergic reactions. Having been informed for the risks, I still wish to proceed and accept all associated risks.
Release
*
To Waive and Release, to the fullest extent permitted by law, each of the artists in the piercing studio and CM HURT, Inc. from all liability whatsoever for any and all claims or cause of actions that I, my estate, heirs, executors or assignees.
Questions
*
That both the artist and CM Hurt, Inc have given me the full opportunity to ask any and all questions about my procedure.
Aftercare
*
I have received full aftercare instructions and they are repeated in person at my appointment, verbally and in writing.
Duress
*
I am not under the influence of drugs or alcohol and am not under duress.
Medical Conditions
*
I will notify my piercer and staff if I have any medical condition that may impact my piercing such as, diabetes, epilepsy, hemophilia, heart condition or blood thinning medication. I have no other skin or medical conditions that may impact the piecing.
I am not pregnant or nursing.
Permanent Change
*
I acknowledge that the peircing may result in a permanent change to my appearance and that my skin may not be restored to it's pre-piercing condition even after it's removal.
This Document
*
I acknowledge that I have been given adequate opportunity to read and understand this document and it was not presented at the last minute. I under stand that I am signing a legal contract.
Attorney Fees
*
I agree to reimburse each artist and the studio for any attorney fees and costs incurred in any legal action that may arise. I further agree that any legal action shall be presented in Orange County, CA courts.
Photography
I release all rights to pictures taken of my piercings/jewelry and give advance consent for the publication of them. If I do not want photographs, please let us know.
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.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Legal Name:
*
Chosen name:
Address:
Postcode:
*
Date of birth:
*
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If you are under
18
your parent/guardian will be required
Phone #:
*
Email:
*
Signature:
*
Sign above or type signature:
Parent/Legal Guardian
I, as custodial parent or legal guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this release form and I attest that all documentation I have provided is true and accurate.
Parent or Legal Guardian must sign and accompany the minor.
Guardian's Legal Name:
*
Relationship:
*
-select-
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
Signature:
*
Photo ID
*
Please take photo(s) of your government issued photo IDs and related paperwork.
Remove Photo