Waiver Form | Pierced by Jordan

BOOK AN APPOINTMENT

For Piercing Client: First Name

Last name

Date of Appointment

Month

Day

Year

Client Address

Phone

Allergies, if any

Client Birthday

Month

Day

Year

Current Client Age

Earring Style Number (if known at time of signing)

Piercing Location

Earlobe

Cartilage

Both

In signing this release and authorization, I acknowledge and represent that:

A. I have read this release form, understand it, and sign it voluntarily.

B. I acknowledge receipt of and understand the aftercare instructions and the risk of infection, I understand that I must carefully follow all aftercare instructions.

C. If having my cartilage pierced, I acknowledge, that I am fully aware that cartilage piercing may carry a greater risk of infection/complication due to improper care of my pierced ears. Should a problem occur, I should seek medical attention immediately.

D. I understand that if I am taking blood thinning medications, have diabetes, may be pregnant, or have a medical problem or history, I should obtain a doctor's approval before a piercing is performed. Pregnant women can usually not ingest medication should an infection occur.

E. I understand that the piercing has sharp tip and agree to follow the aftercare instructions to avoid tip exposure.

I certify that I consent to have my ear(s) pierced by, Pierced by Jordan LLC. I assume all responsibility for injury or loss of any kind that may be associated with this ear piercing and agree to release and hold harmless Pierced by Jordan LLC and Inverness from any and all actions and liability resulting from or relating to this ear piercing. I have read and understand the statements above and acknowledge and agree to each of them.

Photographic Release: I grant permission and consent to Pierced by Jordan LLC for use of a close-up photograph of the piercing for presentation under any legal condition including publicity advertising, marketing and web content. I understand there should be no payment of royalties, or revocation for this release.

Yes, I give Pierced by Jordan LLC permission to use close up photographs of the piercing as described above.

No, I do not give permission for photographys to be used.

Is the client being pierced under 18 years old?

Yes

Parent or Legal Guardian Full Name

Relationship to Client

Parent

Legal Guardian

I represent and certify that I am over 18 years of age or if given on behalf of a minor, that I am the parent or legal guardian of such minor, and I will hold only myself liable and will indemnify, defend, and hold harmless, Pierced by Nurse Jordan LLC and Inverness in the event such minor makes a claim as a result of ear piercing. I understand a minor signing as an adult or an adult falsifying information constitutes a legally fradulent act.

I certify that I am the parent or legal guardian of the minor named above and agree to the statement above.

Printed Name

Date

Month

Day

Year

Signature

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Please complete the Piercing Waiver prior to your scheduled appointment. This form is required for every client being pierced and helps ensure Jordan has the information and consent needed before your appointment begins. If the client is under 18, a parent or legal guardian must complete and sign the form on their behalf.