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r <br /> LOTUS <br /> 3200 N.Naglee Rd,#116,Tracy,CA,95304 <br /> CONSENT TO PIERCE & RELEASE OF CLAIMS <br /> I acknowledge by signing this Release I have been given the full opportunity to ask tiny and all questions <br /> which I might have about obtaining a piercing from and all my questions have been answered <br /> to my full and total satisfaction.I agree as follows:(PLEASE INITIAL) <br /> 1. 1 do not suffer from medical or skin conditions such as,but not limited to:(Initial all that apply) <br /> (nor does my child) <br /> Keloid or Psoriases Open wounds or Herpes infection. <br /> hypertrophic at the site of the lesions at site of <br /> scarring. Piercing. Piercing. <br /> Diabetes. Hemophilia or Cardiac valve disease Any other risks <br /> other bleeding for bloodborn <br /> disorders pathogens. <br /> 2. I am not pregnant of nursing.(nor is my child) <br /> 3. 1 have advised the Piercer of any allergies to certain metals,allergies to latex,allergies to soaps, <br /> and/or the use of medications of ANY kind. <br /> 4. I have trustfully represented to the Piercer,I am over the age of 18,or I am the parent or guardian <br /> of said minor.: <br /> 5. I'acknowledge that obtaining this piercing is my choice and will result in a permanent change to <br /> my appearance,and that restoring the skin involved in this piercing to its pre-piercing condition is not <br /> possible. <br /> 6. 1 acknowledge infection is always possible as a result of obtaining a piercing. 1 have received <br /> aftercare instructions and I agree to follow all of them while my piercing is healing. <br /> 7. 1 understand thatbleeding,tenderness,and swelling may occur at the site of the piercing while it <br /> is healing. <br /> 8. 1 understand that by getting this piercing I am restricted from physical activities such as but not <br /> limited to;baths,recreational water activities,gardening,and/or contact with animals for the duration <br /> on my healing period. <br /> 9. I undertand that there are no refunds.I also understand that if do decide to opt out,or if I am not <br /> satisfied,I will not be given any money back after I have signed this waiver and paid. <br /> 10. I have informed my piercer of any required antiobiotics I have been prescribed prior to dental or <br /> surgical procedures. <br /> Therefore,I request the Piercer to pierce my I understand this type of piercing usually <br /> takes or longer to heal.I agree to release and forever discharge and hold harmless the <br /> Piercer of all claims,damages or legal actions arising from or connected with my piercing,or the procedure <br /> and conduct used in my piercing. <br /> Date: Telephcine 1)C}B <br /> Name: Name of OR: <br /> Signature: MINOR Signature: <br />