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PLEASE READ AND INITIAL THE BOXES WHEN YOU ARE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SiGNING THIS DOCUMENT 1 In consideration of rec eiving a body piercing from the practitioner at Business") i confirm the following: (together with its employees, apprentices, and agents, the "Body Art All questions about the body piercing procedure have been answered to my satisfaction, and I have been given written aftercare instruction 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 co nsent 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 re ove my jewelry, holes pr scars may b� Left. 7:F vvx�{e,rs:h,d N„A-k �'-v-c ` s awe 'r5 w� l pe��vl�.he�+- y qj} �f �e 50' hc- Pte,reP�. — 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, free piercing, or etc. I am the person on the legal I.D. presented as proof that I am 18 years of age, or the body piercing will be 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 an allergic reaction to the jewelry inserted into the fresh body piercing. _ I understand there is a possibility of getting an infection, and I 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 1 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. 1, 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, and 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