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
The following conditions may increase health risks associated with receiving body art:
*****Section for Legal Guardian if Under 18 Years Old*****