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S3 <br /> 01A83Si11lN83d <br /> Hj1V3H1"LN3'NN08lAV0NSENT TO PIERCE & RELEASE OF CLAIMS <br /> Zia 111 <br /> acknDo3wq dge by signing this Release I have been given the full opportunity to ask any and all <br /> might have about obtaining a piercing from Jose(ZOMBIE)Zunig <br /> C13ALVMtions have been answered to my full and total satisfaction. I acknowledge I have <br /> been advised of the matters set forth below and I agree as follows: <br /> 1. I am not pregnant or nursing. If I have any condition that might affect the healing of this <br /> piercing,I will inform my piercer. <br /> 2. 1 do not suffer from medical or skin conditions such as, but not limited to: keloid or <br /> hypertrophic scarring, psoriasis at the site of the piercing or any open wounds, lesions or <br /> Herpes at the site of the piercing. <br /> 3. Do you have any history of hemophilia or other bleeding disorder, Diabetes or any heart <br /> conditions such as cardiac valve disease <br /> 4. 1 have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I <br /> acknowledge it is not reasonably possible for the Piercer to determine whether I might have an <br /> allergic reaction to the piercing or processes involved in the piercing and further acknowledge <br /> that such a reaction is possible. <br /> 5. 1 have trustfully represented to the Piercer I am over the age of 18 years. I am not under the <br /> influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or <br /> medical impairment or disability which might affect my well-being as a direct or indirect result <br /> of my decision to have a piercing done at this time. <br /> 6. 1 acknowledge that obtaining this piercing is my choice alone and will result in a permanent <br /> change to my appearance, and that no representation has been made to me as to the ability to <br /> later restore the skin *involved in this piercing to its pre-piercing condition. <br /> C* 7. 1 acknowledge infection is always possible as a result of obtaining a piercing. I have received <br /> aftercare*instructions and I agree to follow all of them while my Piercing is healing. <br /> 8. 1 am not on any medical medications from any prior surgery or dental procedures and if so <br /> please list: <br /> 9. 1 understand I will be pierced using appropriate instruments and sterilization. <br /> Therefore, I request the Piercer to pierce my . I understand this type <br /> of piercing usually takes or longer to heal. I agree to <br /> release and forever discharge and hold harmless the Piercer and all employees from any and all <br /> claims, damages or legal actions arismg from or connected in any way with my piercing, or the <br /> procedure and conduct used in my piercing. <br /> Dated this day of 20 <br /> NAVE: <br /> Address: <br /> Age: Drivers License No: <br /> Signature: <br />