minor piercing consent form

Date of Piercing

I acknowledge that by signing this agreement I have been given the chance to ask any and all questions I have about the obtaining of a piercing and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I:

I and my child are not under the influence of alcohol or drugs or taking medication that thins the blood.
I have advised my child’s piercer if they have any communicable disease or heart condition such as Diabetes, Epilepsy, Hepatitis, Hemophilia, HIV/AIDS.
My child does not have any health or skin conditions that may interfere with said piercing.
I acknowledge that it is not reasonable for the piercer or employees of Caffeinated Caterpillar LLC to determine whether my child might have an allergic reaction to the jewelry or process of the piercing, and as such I agree to accept the risk that such a reaction is possible.
I acknowledge that infection is possible as a result of my child obtaining said piercing, particularly in the event that I and my child do not take proper care of my child’s piercing, and assume this risk. I have received aftercare instructions and I agree to follow them while my child’s piercing is healing.
I understand that if my child has any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it can result in adverse changes to said piercing.
I understand that my child’s piercer is not a medical professional and any suggestions are not construed as or substituted for advice from any medical professional.
I acknowledge that while my child is being pierced, employees of Caffeinated Caterpillar LLC, may photograph or film the process. I release this content for commercial and non commercial uses.
I acknowledge I am the legal parent or guardian and have truthfully represented this to my underage child’s piercer, and that getting their piercing is your and your child’s choice and no one else’s. I consent to the application of the piercing and to any actions or conduct of the representatives and employees of Caffeinated Caterpillar LLC reasonably necessary to perform the piercing procedure.
To my knowledge my child does not have a physical, mental or medical impairment or disability, which might affect their well being as a result of said piercing.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion will 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.

Parent/Guardian Name

First

Last

Minor's Name

First

Last

Date of Birth

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Piercer

Where is your Piercing going?

Ear, Navel, Nose

Date Any to

List Any Allergies

List Any Conditions That May Affect Healing

Drivers License

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License or State ID

ID Number

Minor's Photo ID

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License or State ID

ID Number

Birth Certificate

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All names must match valid photo IDs per NE DHHS 172 NAC 44.012.03(B)

Signature

Clear Signature