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IN&MED CONSENT TO BODY PIEAG PLEASE READ AND CHECK THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT In Consideration of receiving Piercing from I , the practitioner at UPTOWN INK , (together with its employees, apprentices, and agents.) I confirm the following: All questions about the body piercing procedure have been answered to my full satisfaction, and I have been given written aftercare instructions for the body piercing I am about to receive. I have been informed about what I can expect following the body piercing listed on the informed body piercing consent form, including medical complications that may occur following this body piercing. I understand that body piercing can result in nerve damage, bone and tooth loss, and that if I choose to remove my jewelry, holes or scars may be left. I am the person on the legal ID presented as proof that I am at least 18 years of age, or the body piercing will be performed in the presence of my parent or legal guardian. I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing without duress or coercion. I understand there is a possibility of an allergic reaction to the jewelry inserted into the fresh body piercing. I understand there is a possibility of getting an infection,and 1 have been advised of the signs and symptoms of infection that indicate a need to seek medical attention. I agree to follow all instructions concerning the care of my body piercing. I understand that there is a chance I might feel lightheaded or dizzy during or after being pierced. I agree to immediately notify the body piercer in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. I agree to release and forever discharge and forever hold harmless UPTOWN INK and its associates, agents, and officers from any and all claims, damages, or legal actions arising from or connected in any way with my body piercing received by UPTOWN INK and its associates, agents and representatives in the future. I, have been fully informed of the risks of body piercing's including but not limited to infection and other medical complications, allergic reactions to metal jewelry, latex gloves and antibiotics. Having been informed of the potential risks associated with receiving a body piercing, and I still wish to proceed with the procedure. I assume any and all risks that may arise from the body piercing. Signed Date Practitioner USE ONLY: TOTAL=$ Batch# Date Piercing Type GAGE 10 12 14 16 18 Other