Body Modification Indemnity Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Gender

MaleFemale

Health and Medical Information

	Yes	No
Have you been diagnosed with Hepatitis or any communicable disease?
Do you have Diabetes?
Are you taking any blood thinner?
Do you have difficulty in stopping of bleeding?
Do you have heart-related concerns?
Are you pregnant? (for females)

Do you have any allergies?

Please explain

	Yes	No
Did you consume any alcoholic drink or taken drugs in the past 8 hours?
Have you consumed food in the past 2 hours?

Do you have any condition that might affect your bodily healing?

If yes, please explain

I hereby declare that the information I have specified above is true and correct to the best of my knowledge which may otherwise give adverse effects, should I undergo any of the services. I have been informed by my piercer/artist that any conditions that would exist before the procedure would hamper the healing process of my body. I have been advised by my piercer/artist regarding any allergies, including allergic reactions to latex, metals, and/or medications.

I understand that changes made to my body shall be permanent and without possibility of reversal. I likewise understand that performing the procedure is not a procedure done by a healthcare professional. I understand that the procedure shall be done with proper techniques and properly sanitized instruments. In no case, I acknowledge infection is always possible after a procedure. I have received aftercare instructions and agree to follow all of them while my piercing is healing.

By signing this form, I hereby release, forever discharge and hold harmless the company, its employees, owners, managers, directors, partners, and affiliates from any and all claims for liabilities and damages or hold them liable for any criminal or civil proceedings arising from or connected to the procedure undertaken.

I am executing this indemnity form with full knowledge and understanding to its legally binding effect. I acknowledge that I am of legal age giving my full consent to this indemnity agreement, without representation, inducement, or coercion.

Signature

Date