Forms

Piercing waiver

Consent: application for piercing, release of liability and waiver to all claims

Zero Regrets Tattoo And Piercing · 100 Vann Drive, Jackson, TN 38305 · (731) 300-3210 · [email protected]

Client ID and signature

Upload a current, valid ID photo

Choose a photo from your phone album or take a new one. Full card, in focus, not expired.

I confirm this is a current, valid, unexpired government ID and the photo is of that ID.

ID type

Signature — type your full legal name

Bio

First name

Last name

Date of birth

Age

Gender

Phone number

Street address

City

State

Zip code

Country

Emergency contact

Emergency contact phone

How did you find us?

Referred by

Email opt-in

Email address

The piercing

Date of this session

Piercer name

Type of piercing

Description

Health

Allergies

Latex

Fragrance

Neomycin

Nickel

Adhesive

Silver

Rubber

Povidone-iodine

Gold

Acrylic

Diseases

Staph infection

HIV/AIDS

Hepatitis C

Skin infection

STD/STI history

Tuberculosis

Herpes (HSV-2)

Cold sores (HSV-1)

Hepatitis B

MRSA

Health conditions

Allergic to adhesives

Diabetes

Autoimmune disorder

Heart disease

Epilepsy

Asthma

Hypertension

Pregnancy

Blood clotting disorder

Keloid formation

How long since you last ate

Are you taking any medications

Legal

By completing and signing this form, I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing from Zero Regrets Tattoo And Piercing and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth, and I agree as follows (please initial each statement below). You must be 18 or older to be pierced at this shop.

I do not have any chronic illness or condition that may affect healing.

I acknowledge that pain and discomfort are normal parts of the procedure.

I am not pregnant or breastfeeding.

I agree to follow the provided aftercare instructions.

I understand the risks involved in the piercing procedure.

I release the piercer and studio from liability for any adverse reactions.

I understand that I should seek medical attention if complications arise.

I have no known allergies to metals, plastics, or dyes used.

I consent to the use of photographs taken during the procedure for promotional purposes.

I confirm that I am over 18 years of age. This shop does not pierce anyone under 18.

The form will not send until every field is filled, every statement is initialed, the signature matches your legal name, and a current valid ID photo is attached. You must be 18 or older.