WAIVER, RELEASE AND CONSENT TO PIERCING

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF

SIGNING

THIS DOCUMENT IS TWO PAGES [Or Two Sided]. PLEASE INITIAL EACH PROVISION ON THE
LINES PROVIDED AFTER READING TO SHOW THAT YOU UNDERSTAND EACH PROVISION.

In consideration of receiving a body piercing from _________ at Mystic Images (together with its
employees, apprentices and agents, the “Piercing Studio”), I agree to the following:

That I, ______________________________ (clearly PRINT your name) have been fully

informed of the inherent risks, associated with getting a piercing. I fully understand that
these risks, known and unknown, can lead to injury, including but not limited to infection,
scarring and keloiding, allergic reactions to jewelry, latex gloves, and/or soap. Having been
informed of the potential risks associated with getting a piercing, I still wish to proceed with
the piercing and I freely accept and expressly assume any and all risks that may arise from
piercing.

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the
Piercing Studio from all liability whatsoever, for any and all claims or causes of action that I,
my estate, heirs, executors or assigns may have for personal injury or otherwise, including
any direct and/or consequential damages, which result or arise from the piercing, whether
caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise.

That both the Artist and the Piercing Studio have given me the full opportunity to ask any
and all questions about the piercing procedure and the staff has answered these questions
to my total satisfaction.

I affirm that both the Artist and the Piercing Studio have given me instructions on the care
of my piercing while it’s healing, and I understand them and will follow them. I acknowledge
that it is possible that the piercing can become infected, particularly if I do not follow the
instructions given to me.

I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a
piercing without duress.

I affirm that I do not have diabetes, epilepsy, hemophilia, nor do I have a heart condition or
take blood thinning medication. I do not have any other medical or skin condition that may
interfere with the procedure or healing of the piercing. I am not the recipient of an organ or
bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-
biotics that is required by my doctor in advance of any invasive procedure such as piercing.
I am not pregnant or nursing.

I acknowledge that the piercing will result in a permanent change to my appearance and
that my skin may not be restored to its pre-piercing condition even after its removal.

I release all rights to any photographs taken of me and the piercing and give consent in
advance to their reproduction in print or electronic form. (If you do not initial this provision,
please advise and remind your Artist and the Piercing Studio NOT to take any pictures of
you and your completed piercing!).
 I acknowledge that I have been given adequate opportunity to read and understand this
document, that it was not presented to me at the last minute, and I understand that I am
signing a legal contract waiving certain rights to recover against Piercing Studio.

I agree to reimburse each of the Artist and the Piercing Studio for any attorneys’ fees and
costs incurred in any legal action I bring against either the Artist or the Piercing Studio and
in which either the Artist or the Piercing Studio is the prevailing party. I agree that the that
the courts of Indiana in Hamilton County shall have personal jurisdiction and venue over
me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out
of or related to this agreement.

I acknowledge that I have been given adequate opportunity to read and understand this
document, that it was not presented to me at the last minute, and I understand that I am
signing a legal contract waiving certain rights to recover against the Artist and the Piercing
Studio.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or
invalid, that portion shall be severed from this contract. The remainder of this contract will then be
construed as though the unenforceable portion had never been contained in this document.

I hereby declare that I am of legal age (and have provided valid proof of age) and am competent to sign
this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or
legal guardian is in complete understanding and concurrence with this agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.

Print Full Name: ___________________________________ Date of Birth: ________________Age:_____

Address: ___________________________________ Telephone: ________________

Signature of Participant: ___________________________________ Date: ________________

Signature of Parent or Guardian if Participant Is a Minor

and by their signature they, on my behalf, release all claims that both they and I have.

Signature: ___________________________________ Date:

________________

Desired Piercing Price:

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