Ear Piercing Consent, Waiver, and Release Form

Your Name *

Your Email *

Phone *

Date of birth *

Minor's Name

If applicable

Minor's Date of birth

Please checkmark for consent: *

I acknowledge that if I am taking blood thinning medications, antibiotics, steroids, or antihistamines that ear piercing may carry a greater risk for me.

I acknowledge that if I am diabetic, immune-comprised, have high blood pressure, am pregnant, have epilepsy, history or syncopal (fainting) episodes, needle phobia, have hemophilia or other bleeding disorders, or have a heart condition that ear piercing may carry a greater risk for me, and I wish to proceed.

I understand that ear piercing is a minor surgical procedure with similar risks to stitches or abscess drainage. Despite all precautions that are taken by your medical professional and my proper following of aftercare, the potential for infection still exists. There is also the potential that one of the following complications may occur as a result of ear piercing: Persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, cellulitis, blood poisoning (septicemia), keloids, cauliflower ear, pressure sore or traumatic injury. I agree to immediately contact a health care provider should I experience any of these conditions. I understand that my failure to do so could exacerbate any complications.

I have read and understand the AFTER-CARE INSTRUCTIONS. Aftercare of piercing is the responsibility of the customer or parent once they leave the office.

I have agreed to this ear piercing procedure and am fully aware of the potential risks and complications. I have read and understand all the terms listed above and agree to their terms.

I understand that Piercd and all Piercd Providers aim to offer a positive piercing experience. If a child is unwilling to receive an ear piercing at any point during the process, the piercer reserves the right to discontinue the service. I understand I will be offered a gift card for any services unfulfilled, i.e. if one ear piercing is complete and not the other.

I understand that my time slot is for max 20 minutes only. My appointment will be ended and can be rescheduled for another time if the child becomes unwilling to receive ear piercing or the time allotted exceeds 30 minutes.

I understand that restraining a child to perform a piercing will not be allowed. Piercd and all Piercd Provider’s goal is to offer an enjoyable experience for everyone who receives an ear piercing.

ASSUMPTION OF RISK *

I AM AWARE AND UNDERSTAND THAT EAR PIERCING IS A POTENTIALLY DANGEROUS ACTIVITY AND INVOLVES THE RISK OF THE CONDITIONS LISTED ABOVE AND OTHER SERIOUS MEDICAL CONDITIONS. I ACKNOWLEDGE THAT ANY INJURIES THAT I MAY SUSTAIN MAY RESULT FROM OR BE COMPOUNDED BY THE ACTS, OMISSIONS, OR NEGLIGENCE OF PIERCER. NOTWITHSTANDING THE RISK, I ACKNOWLEDGE THAT I AM VOLUNTARILY PARTICIPATING IN THE PIERCING WITH KNOWLEDGE AND AN EXPRESS UNDERSTANDING OF THE RISK INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY AND ILLNESS ARISING FROM MY PARTICIPATION IN THE PIERCING, WHETHER CAUSED BY THE NEGLIGENCE OF PIERCER OR OTHERWISE.

WAIVER OF LIABILITY *

I HEREBY EXPRESSLY WAIVE AND RELEASE ANY AND ALL CLAIMS, NOW KNOWN OR HEREAFTER KNOWN, AGAINST PIERCER, EMBARK FINE JEWELRY, LLC, PIERCD, LLC, ALL PIERCD PROVIDERS AND THEIR OFFICERS, DIRECTORS, MANAGERS, EMPLOYEES, AGENTS, AFFILIATES, MEMBERS, SUCCESSORS, AND ASSIGNS (COLLECTIVELY, “RELEASEES”), ON ACCOUNT OF INJURY OR ILLNESS ARISING OUT OF OR ATTRIBUTABLE TO MY PARTICIPATION IN THE PIERCING, WHETHER ARISING OUT OF THE NEGLIGENCE OF PIERCER OR ANY RELEASEE OR OTHERWISE. I COVENANT NOT TO BRING ANY SUCH CLAIM AGAINST PIERCER OR ANY RELEASEE, AND FOREVER RELEASE AND DISCHARGE PIERCER AND ALL RELEASEES FROM LIABILITY UNDER SUCH CLAIMS.

EMAIL & TEXT CONSENT *

BY CHECKING OFF AND SUBMITTING THIS FORM, YOU AGREE TO RECEIVE RECURRING AUTOMATED PROMOTIONAL AND PERSONALIZED MARKETING TEXT MESSAGES AND EMAILS (E.G. CART REMINDERS) FROM EMBARK FINE JEWELRY AND PIERCD AT THE CELL NUMBER AND EMAIL USED WHEN SIGNING UP. CONSENT IS NOT A CONDITION OF ANY PURCHASE. REPLY HELP FOR HELP AND STOP TO CANCEL. MSG FREQUENCY VARIES. MSG AND DATA RATES MAY APPLY. I AGREE TO THESE TERMS AND CONDITIONS.

CONSENT *

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTOOD ALL OF THE TERMS OF THIS RELEASE AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE PIERCER AND ALL RELEASEES, WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME. I COMPLETELY AND UNCONDITIONALLY RELEASE ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW

✖ *

Print Name

Relationship to customer (if customer is under 18)

Date

Ear Piercing Consent, Waiver, and Release Form

Embark Fine Jewelry

Embark Fine Jewelry