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• •MINOR CONSENT TO PIERCE & RELEASE OF CLAIMS I ,the parent/legal guardian of Induce to pierce my son and/or daughter. In consideration of doing so, I fully understand THE PIERCER DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as/or substituted for advice from a medical professional. I acknowledge by signing this Release I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing and all my questions have been answered to my full and total satisfaction. I acknowledge I have been advised of the matters set forth below and I agree as follows: 1My child is not pregnant or nursing. He/She does not have any condition that might hamper healing of the piercing. 2 3Does He/She have any history of hemophilia or other bleeding disorder,Diabetes or any heart conditions such as cardiac valve disease if so please let the artist know 4 5 He/She does not suffer from medical or skin conditions such as,but not limited to:keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds,lesions herpes at the site of the piercing. 11 have advised the Piercer of any allergies to metals,latex gloves,soaps and medications. I acknowledge itis not reasonably possible for the Piercer to determine whether He/She might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible. 2 3Does your child have any allergic to any antibiotics? 4 5My Child is not under the influence of drugs or alcohol. To my knowledge,He/She does not have any physical, mental or medical impairment or disability which might affect his/her well-being as a direct or indirect result of my decision to have a piercing done at this time. I I acknowledge that obtaining this piercing is my child's choice alone and will result in a permanent change to his/her appearance,and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition. I I acknowledge infection is always possible as a result of obtaining a piercing. My child and I have received aftercare instructions and We agree to follow all of them while the piercing is healing. 2 3Does your child have a history of medications use or is currently using medication,including prescribed antibiotics prior to dental surgical procedures please list: 4 5Does your child have HIV,Hepatitis B,Hepatitis C or and other blood borne pathogens? 6 11 understand he/she will be pierced using appropriate instruments and sterilization. Therefore, I request the Piercer to pierce my son/daughter's I understand this type of piercing usually takes or longer to heal. I agree to release and forever discharge and hold harmless the Piercer and all employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in his/her piercing. By my signature below, I certify that I am the parent legal guardian of , who is willingly submitting to these procedures. Signature(Parent/Legal Guardian) Print Name: Signature(Piercee) Print Name: Date: Parent/Legal Guardian Lic#: