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LOST DREAMS TATTOO AND PIERCING PLEASE READ AND INITIAL THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS DOCUMENT In consideration of receiving a body piercing from the practitioner at Lost Dreams Tattoo and Piercing(together with its employees, apprentices and agents,the "Body Art Business") I confirm the following: All questions about the body piercing procedure have been answered to my 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/vein damage, bone and tooth loss and that if I choose to remove my jewelry, holes or scars maybe left. I understand that piercings are permanent and that getting a piercing will permanently alter the site being pierced. I understand that there is a possibility that my body piercing may reject,fall out,or will not heal correctly and I assume all risks involved with the body piercing;and that I am not entitled to a refund, or free piercing etc. I am the person on the legal I.D. resented as roof that I am 18 ears of age,or the body piercing will be P g p p Y g Yp g performed in the presence of, or as directed by a notarized writing, by 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 getting an infection and I have been advised of the signs and symptoms of p Y g g g 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, have been fully informed of the risks of body piercing 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, I still wish to proceed with the procedure. I assume any and all risks that may arise from the body piercing. Date Client Signature Date Parent Signature