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the <br /> Ie6nsaerauon 'i ®f R <br /> {N eifi PeoraMone4 <br /> r _ ' <br /> and <br /> (Narne of Body Art s) <br /> gents,the" ", <br /> coiffinn the following: <br /> All questions about the body piercing procedure n answered to y Satisfaction, d i h <br /> ave <br /> been given ri n aftercare instructions for thepiercing to receive. <br /> 1 have been informed about what 1 can expect following thebody i t listed i Y <br /> piercingconsent form, includingmedical li ions occur foo in is body piercing. <br /> 1 understand that body piercing n result in nerve a nand tooth loss, and that if 1 choose to <br /> remove my jewelry, holes or scars may be left. <br /> I am the person ont legal i t as proof that I am at least 18 years of age,ort ie in <br /> will be performedin the presence of, or as directed by a notarized writing, y parent or legal <br /> guardian. <br /> ant n under the influenceof alcohol t and t E 1 am voluntarily s i 'n b y 'ercin <br /> without duress coercion. <br /> 1 understand there is a possibilityof an allergic reaction to the jewelry inserted into the fresh body <br /> piercing. <br /> I understand there is a possibifity of getting an infection, and 1 have been advised of the signs and <br /> symptoms infection that indicate a need to seek medicalattention. <br /> 1 agree to follow all instructions concerning the r y body piercing. <br /> 1 understand that ere is a chance 1 might feel lightheaded or dizzy during orafter being pierced. <br /> 1 agree to immediately notify the body piercer in the event 1 feel lightheaded, dizzy or faint <br /> before, during or after the procedure. <br /> 1 have been fully informed f the risks of body <br /> piercing-frictuding but not limited o infection and other medical pli ions, ler is `ons o metal <br /> jewelry, l" ex lou and iota Having in informedthepotential risks _` receiving a <br /> body tang, and 1 still wish to proceed with the procedure. l assume any and all risks that may arise from <br /> the body piercing. <br /> Sign D <br /> ate <br /> Bods Piercing Page 2 of, 2 <br />