Laserfiche WebLink
9 <br /> PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS <br /> OF SIGNING THIS DOCUMENT <br /> In consideration of receiving a body piercing from <br /> (Name of Practitioner), practitioner at (Name of Business) <br /> I confirm the following: <br /> I am not pregnant. <br /> _I do not have a history of herpes infection at the proposed procedure site,diabetes,allergic reactions <br /> to latex or antibiotics,hemophilia or other bleeding disorder,or cardiac valve disease. <br /> _I do not have a history of medication use or is currently using medication,including being prescribed <br /> antibiotics prior to dental or surgical procedures. <br /> _ All questions about the body piercing procedure have been answered to my satisfaction,and I have <br /> been given written aftercare instructions for the body piercing I am about to receive. <br /> _I have been informed about what I can expect following the body piercing listed on the informed <br /> body piercing informed consent form,including medical complications that may occur following this <br /> body piercing. <br /> _I understand that body piercing can result in nerve damage,bone and tooth loss,and that if I choose <br /> to remove my jewelry,holes or scars may be left. <br /> _I am the person on the legal ID presented as proof that I am at least 18 years of age,or the body <br /> piercing will be performed in the presence of,or as directed by a notarized writing,by my parent or legal <br /> guardian. <br /> I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing <br /> without duress or coercion. <br /> 1 understand there is a possibility of an allergic reaction to the jewelry inserted into the fresh body <br /> piercing. <br /> I understand there is a possibility of getting an infection,and I have been advised of the signs and <br /> symptoms of infection that indicate a need to seek medical attention. <br /> I agree to follow all instructions concerning the care of my body piercing. <br /> _I understand that there is a chance I might feel lightheaded or dizzy during or after being pierced. <br /> I agree to immediately notify the body piercer in the event I feel lightheaded,dizzy and/or faint <br /> before,during or after the procedure. <br /> I, have been fully informed of the risks of body <br /> piercing including but not limited to risk factors for bloodborne pathogen exposure, infection and other <br /> medical complications,allergic reactions to metal jewelry, latex gloves,and antibiotics. Having been <br /> informed of the potential risks associated with receiving a body piercing,and I still wish to proceed with <br /> the procedure.I assume any and all risks that may arise from the body piercing. <br /> Signed: Date: <br />