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  • The Galactic Gem

    8326 consumer ct Sarasota Fl, 34202
  • Page 1 of 4
  • Client Intake, Consent & Release Form

  • CLIENT INFORMATION

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  • Format: (000) 000-0000.
  • PIERCING DETAILS

    STAFF ONLY
  • HEALTH HISTORY (Please write clearly)

  • EMERGENCY & PHYSICIAN CONTACT (NOT 911)

  • This is a fill in the field. Please add appropriate fields and text.

  • Format: (000) 000-0000.
  • Primary Physician: If none please list preffered walk in clinic.

  • Format: (000) 000-0000.
  • The Galactic Gem: 8326 consumer ct Sarasota Fl, 34202

  • The Galactic Gem
  • Page 2 of 4
  • ACKNOWLEDGMENT, RELEASE & WAIVER OF LIABILITY(PLEASE INITIAL EACH LINE AFTER READING)

  • The Galactic Gem: 8326 consumer ct Sarasota Fl, 34202

  • The Galactic Gem
  • Page 3 of 4
  • 6. AFTERCARE RESPONSIBILITY

  • I have received and understand the verbal and written aftercare instructions. I agree to follow them exactly. I accept full and complete responsibility for the aftercare and healing of my piercing. I agree to check my jewelry monthly for tightness and return for a downsize when advised (About 4 weeks.) I understand that any follow ups/ touch-ups or corrections needed due to my negligence or failure to follow aftercare instructions will be at my own expense. I agree that The Galactic Gem may update aftercare instructions based on the most current medical standards. I agree to notifiy The Galactic Gem of any issues that may occur in the healing process. 

  • 7. NO GUARANTEE & LIMITATION OF LIABILITY

  • I understand that body piercings tattoos and body art are not guaranteed to heal perfectly or at all due to factors beyond the studios control, such as my own anatomy, hygiene, and aftercare practices, clothing etc. The Galactic Gem will provide aftercare instructions and, at its discretion, troubleshooting advice for common healing issues. I understand this advice is for informational purposes only and is not a substitute for the diagnosis or treatment of a licensed medical professional.

  • 8. COMPLETE RELEASE OF LIABILITY (HOLD HARMLESS AGREEMENT)

  • Being of sound mind and body, I hereby agree to release, discharge, and hold harmless "The Galactic Gem", its owners, employees, agents, and representatives from any and all claims, demands, damages, rights, causes of action, or liability of any kind arising from my decision to have this piercing/procedure, including any complications during or after the healing process. This release applies whether the claim is based on alleged negligence or any other cause of action, and it includes any injury, damage, or loss to myself or my property.
  • 9. STUDIO POLICIES & LEGAL TERMS

  • I understand that all sales are final. There are no refunds on services or jewelry once the procedure has begun. I understand a $25 reinsertion fee will apply if jewelry is lost or removed before the recommended healing time and must be reinserted. Reinsertion is not guaranteed if the channel has closed. I understand that The Galactic Gem reserves the right to refuse service to anyone at any time for any reason, including safety concerns, intoxication, or hostile behavior or any other reason. I agree that any legal disputes will be resolved in the courts of Manatee County, Florida.
  • FINAL CLIENT CERTIFICATION

  • By signing below, I swear that all information provided is true and accurate. I have been given the opportunity to ask questions, which have been answered to my satisfaction. I have read, understood, and initialed each section of this agreement. I am not under the influence of alcohol or drugs. I consent to the piercing procedure voluntarily and agree to all terms outlined in this document.
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  • The Galactic Gem: 8326 consumer ct Sarasota Fl, 34202

  • FOR STUDIO USE ONLY:

  • The Galactic Gem: 8326 consumer ct Sarasota Fl, 34202

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