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BACKSTAGE PIERCING CONSENT FORM 

4472 PALISADES CENTER DRIVE WEST NYACK, NY 10994 – (845).727.4909

CONSENT, RELEASE AND WAIVER OF ALL CLAIMS

I hereby acknowledge to obtain a piercing and have been given full opportunity to ask any and all questions I might have about obtaining piercing from Backstage, and all my questions have been answered to my full and total satisfaction. 

I specifically acknowledge that I have been advised of the following: 

1. Obtaining this piercing is my choice alone and will result a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing conditions. 

2. It is not reasonably possible for the piercer to determine whether I have an allergic reaction to the piercing or process in the piercing and further acknowledge that such a reaction is possible. 

3. I will be pierced using appropriate instruments and sterilization techniques 

4. I have been advised of all the procedures necessary to promote satisfactory healing of my piercing 

5. Infection is always a possible result of obtaining a piercing, and I agree to follow all the instructions concerning the care of my piercing while it is healing 

6. I am aware and have been advised of the potential danger oral jewelry may cause to gum and teeth. 

7. I must consult a health care provider for: unexpected redness, tenderness, swelling , unexpected drainage at the site of the piercing, any rash or a fever within (2) hours of the body art procedure

I represent to my piercer that:

* I am not pregnant or nursing

* I do not have Epilepsy or Hemophilia 

* I do not have heart conditions or take any medications such as anticoagulants that thin my blood 

* I do not have any history of skin diseases or skin conditions such as, but not limited to, Keloids, Hypertrophy scarring, Psoriasis, Lesions or open wounds at the site of the piercing 

* I do not have HIV, Hepatitis or any other communicable disease 

* I have advised the piercer of any allergies 

* I am over the age of 18 

* I am not under the influence of drugs or Alcohol 

* I do not have any physical or mental impairment or disabilities, which might affect my well being as a result of my decisions to have a piercing done at this time

 
 
Please select at least one choice above.

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

  • History of Diabetes
  • History of Hemophilia (bleeding)
  • History of 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, (Coumadin) which thin the blood and/or interfere with blood clotting
  • Hepatitis, HIV or any other communicable disease
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*****Section for Legal Guardian if Under 18 Years Old*****

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CONSULT HEALTH CARE PROVIDER FOR:

  • Unexpected redness, tenderness or swelling at the site of the piercing
  • Rash
  • Unexpected drainage at or from the site of the piercing
  • Fever within 24 hours of the piercing