PIERCING CONSENT FORM

First name

Email

Last name

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

DRIVER'S LICENSE/ID NUMBER

COPY OF PHOTO ID

PLEASE HAVE YOUR ARTIST TAKE A PHOTO OF YOUR ID TO UPLOAD HERE

TYMBRE

PATRICK ROMSA

PLEASE CHECK ALL TO ACKNOWLEDGE * Required

I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be pierced that may interfere with said piercing. If I have any type of infection or rash anywhere on my body, I will advise my piercer.

I acknowledge it is not reasonably possible for the representatives and employees of Dark Light Studios to determine whether I might have an allergic reaction to the jewelery or equipment used for my piercing, and I agree to accept the risk that such a reaction is possible.

I acknowledge that infection is always possible as a result of the obtaining of a piercing, particularly in the event that I do not take proper care of my piercing. I have received aftercare instructions and I agree to follow them while my piercing is healing.

To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a piercing.

I acknowledge I am over the age of eighteen and that I have truthfully represented to my piercer that the obtaining of a piercing is by my choice alone. I consent to the application of the piercing and to any actions or conduct of the representatives and employees of the tattoo shop reasonably necessary to perform the piercing procedure.

I agree to release and forever discharge and hold harmless Dark Light Studios and all its independent contractors from any and all claims, damages, and legal actions arising from or connected in any way with my piercing and the procedures and conduct used to apply my piercing.

I am not a hemophiliac (bleeder). I do not have diabetes, epilepsy, hepatitis, HIV, AIDS, or any communicable disease. I am not under the influence of alcohol and/or drugs. I am not pregnant or nursing. If I have any condition that might affect the healing of this piercing, I will advise my piercer.

I understand that tattoo(s) are created by hand and the appearance of the artwork will differ from the tattooed procedure.

I agree to release and forever discharge and hold harmless Dark Light Studios and all its independant contractors from any and all claims, damages, and legal actions arising from or connected in any way with my tattoo and the procedures and conduct used to apply my tattoo.

I am not a hemophiliac (bleeder). I do not have diabetes, epilepsy, hepatitis, HIV, AIDS, or any communicable disease. I am not under the influence of alcohol and/or drugs. I am not pregnant or nursing. If I have any condition that might affect the healing of this tattoo, I will advise my tattooer.

I agree to allow any photographs taken by the artist to be used for media advertising such as but not limited to; social media outlets, newspaper, commercials, tv, flyer ads, website, portfolio displays, other marketing materials, etc.

I agree to be put on Dark Light Studios newsletter mailing list. (Note: by giving us your email address you give us permission to contact you. You can opt out at any time by using the opt-out link in the newsletter.)

I understand and agree to Dark Light Studios cancellation policies and understand deposits and gift certificates are non refundable.

I understand and agree that rates and deposits are subject to change at anytime.

Your Signature

Thanks for submitting! IF YOU WERE NOT ABLE TO CHECK ANY BOX DUE TO ANY CONDITIONS, PLEASE INFORM YOUR ARTIST.

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