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PiercinP Consent �4 <br /> CHANGES BEAUrE LOUNGE <br /> EMAiL:CHANCESBEAUTELOUNGL"@)GMAIL.COM �. <br /> RHONE:209.326.4224 <br /> WEB:CHAGESBEAUTL•LOUNGL•.GLOSS(iENIUS.COM <br /> PERSONAL INFORMATION <br /> Name 1)013 AGE <br /> Email Phone <br /> Please read and initial each section below: <br /> I acknowledge chat I have represented to the piecer I am over the a«e of 18 years, am not under the <br /> influence of drugs or alcohol, and i do not have any physical, mental or medic impairment or disability which <br /> might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time. <br /> 1 am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart <br /> conditions or take medication that thins the blood. 1 have informed my piercer of any condition such as diabetes <br /> that might hinder the healing of the piercing. <br /> If I suffer from hepatitis or any other communicable disease, I have informed the piercer of this fact and I <br /> have been advised of any procedures necessary to promote the satisfactory healing of my piercing. <br /> I do not suffer from medical or skin conditions such as, but not limited to keloid or hypertrophic <br /> scarring,psoriasis at the site of the piercing,or any open wounds or lesions at the site of the piercing. <br /> i have advised the piercer of any allergies to metals, latex gloves, soaps, and medications. I acknowledge <br /> it is nor reasonably possible for the Piercer to determine whether 1 might have an allergic reaction to the piercing or <br /> processes involved in the piercing and further acknowledge that such a reaction is possible. <br /> I acknowledge that obtaining; this piercing is my choice alone and will result in a permanent change to <br /> my appearance and that no representation hasbeen made to me as to the ability to later restore the skin involved in <br /> this piercing to its pre-piercing condition. <br /> I acknowledge infection is always possible because of obtaining a piercing. 1 have received aftercare <br /> instructions and I agree to follow all of them while my piercing is healing. <br /> I understand I will be pierced using appppropriate instruments and sterilization. <br /> 1 hereby permit"CHANGES 131 LOUNGE'to pierce (Please identity piercing types/locations): <br /> By signing below. 1 underscand the general nature and risks associated with the piercing service and I voluntarilv elect to <br /> receive the service h1 "CHANGES BtAUTE LOUNGE, I agree that I am over the age cit 18,or ani the parent/leg;al huardian <br /> of a minor seeking c ie piercing;service and can(provide legal c ocumencarion of parent guardianship of minor. I agree c iat 1 will <br /> 1101' hold "CHANGES BEAUTE LOUNGE liable in any way fir any loss, damage, or injury suffered to/b>), me as a <br /> conseduence of an undesired result,allergy whether known or unknown nor my failure to accurately or truthfidly ciisc•lose any <br /> niedic•al conditions. <br /> Na the Date <br />