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CONSENT TO PIERCE & RELEASE OF CLAIMS I acknowledge by signing this release, and I have been given the full opportunity to ask questions which I might have about obtaining a piercing from 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: 1. 1 am not pregnant or nursing. If I have any condition that might affect the healing of this piercing, I will inform my piercer. 2. I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic sear -ring, psoriasis at the site of the piercing or any open wounds, lesions or Herpes at the site of the piercing. 3. I do not have a history of hemophilia or other bleeding disorders, diabetes or any heart conditions such as cardiac valve disease. 4. I have advised the piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible. 5. Do you have any allergies to any antibiotics? Yes or no, if yes please list below: 6. I am at least 18 years old. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time. 7. I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this procedure to its pre -piercing condition. 8. 1 acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and 1 agree to follow all of them while my piercing is heaWi/2- 9. Please list any current medications you are taking, for eNaftie any requirements for antibiotics prior to surgery or dental procedures: 10. Do you have HIV, Hepatitis B, Hepatitis C and/or other risk factors for bloodborne pathogens? Yes or no, if yes please list: 11. I understand I will be pierced using appropriate instruments and sterilization. 12. After the procedure, I should expect redness, swelling & some bleeding. Therefore, I request the piercer to pierce my . I understand this type of piercing usually takes or longer to heal. I agree to release 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 my piercing. Dated this Name: D.o.B: Signature: day of 20