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Birthday
Day
Month
Year
Date and Time of Procedure
Day
Month
Year
Time
HoursMinutes
Do You Have Flu Like Systems?
Yes
No
Have You Eaten In The Past 4 Hours?
Yes
No

It is a good idea to eat beforehand to increase your blood sugar levels.

Do You Have Any Bloodborne Pathogens, Transmittable Diseases or Recent Illnesses?
Yes
No

It is okay if you do, we just need to know for our and other's safety.

Risks
I Accept

I have been fully informed of the risks associated with getting a body piercing. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring, keloiding and allergic reactions. Having been informed of the potential risks, I still wish to proceed with the piercing and freely any and all risks that may arise.

Release Waiver
I Accept

To waive and release to the fullest extent permitted by law each of the individual artists and Eternal Gold piercing studio from all liability whatsoever, for any and all claims 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, whether caused by the negligence or fault of either the artist, Eternal Gold studio, or otherwise.

Questions
I Confirm

That both the Artist and Eternal Gold studio have given me the full opportunity to ask any and all questions about the piercing procedure and that they have been answered to my complete satisfaction.

Aftercare
I Confirm

That I will follow all instructions provided by the Artist on the care of my piercing while it is healing and that I fully understand the instructions. I acknowledge it is possible for the piercing to become infected, particularly if I do not follow the instructions given.

Duress
I Confirm

That I am not under the influence of any alcohol, drugs or illicit substances and that I am voluntarily getting this body piercing without duress.

Medical Conditions
I Confirm

That I do not suffer from diabetes, hemophilia or epilepsy, nor do I have any heart condition or take blood thinning medication. I do not have any medical or skin condition that may interfere with the procedure or healing of the piercing. I am not the recipient of any organ or bone marrow transplant, or if I am, I have properly taken the prescribed preventative regime that is required by my doctor in advance of any invasive procedure such as piercing. I am not pregnant or nursing.

Permanent Change
I Accept

That the piercing I am about to receive will result in a permanent change to my physical appearance and that my skin may never be restored to its pre-piercing condition, even after the removal of the piercing.

This Document
I Confirm

That I have been given sufficient time to read and understand each section of this document and that by completing this form I am signing a legal contract.

Photography
I Confirm

That I release all rights to any photographs taken of me and the piercing and that I give my consent in advance to their reproduction in print or digital form.

Please provide the name and contact details of your emergency contact and their relation to you. In the event of an emergency, they may be required to provide details on your medical history, allergies or medications.

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