PIERCING CONSENT FORM (ADULT)

THE DOLOROSA TATTOO CO.

11930 Ventura Blvd, STUDIO CITY, CA 91604

RELEASE AND CONSENT FOR PIERCING

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING.

I acknowledge by signing this Release I have been given the full opportunity to ask any questions which I might have about obtaining a piercing from...

...and all my questions have been answered to my full and total satisfaction. I acknowledge I have been advised of the matters set forth below and I agree as follows:

I am not pregnant or nursing. If I have any condition that might affect the healing of this piercing, I will inform my Piercer.

I do not suffer from medical or skin conditions such as, but not limited to keloid, or hypermophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.

I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.

I have trustfully represented to the Piercer I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have a piercing done at this time.

I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition.

TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Piercer and The Dolorosa Tattoo and 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 but not limited to, any and/or all consequential damages, which result or arise, whether caused by the negligence or fault of either the Piercer or The Dolorosa Tattoo & Piercing Studio, or otherwise.

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 check this, please remind your piercer to not take any photos of you).

Body Piercing Location (Required)

Body Piercing Price

Jewelry Price before tax

I understand that this piercing will take

...or longer to heal. I agree to release and forever discharge and hold harmless the Piercer and all employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing. I agree to reimburse each of the Piercer and The Dolorosa Tattoo & Piercing Studio and in which either Piercer or The Dolorosa Tattoo & Piercing Studio is the prevailing party.

Personal Information

Legal First Name

Legal Last Name

Preferred Name (if different from above)

Pronouns

Phone number

Date

Date of Birth

City

State

ZIP Code

Government Issued ID (Required) *

Upload a clear photo of your government-issued ID. Max file size 10MB.

Electronic Signature

Type your full legal name as your electronic signature

The information I have provided is complete and true to the best of my knowledge.

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