Legal Guardian Name

Relationship to minor

If other, please explain

Identification Documents

What supporting documents are you providing today?

Select Your Piercer

Piercing Description

I understand that the health conditions outlined above may increase health risks associated with receiving any body art procedure. Please sign below to acknowledge these risks.

Medical History Refusal

I refuse to provide the medical information requested above and understand that refusing this information could cause complications. Please sign below to acknowledge your refusal.

Body Piercing Procedure Consent and Release

-I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body piercing without duress or coercion. -The information that I have provided in the medical questionnaire is complete and true to the best of my knowledge. -I acknowledge that body piercing is a semi-permanent change to my appearance and that no representations have been made to me as to the ability to later change, alter or remove my body piercing without scarring or marks remaining. -I understand and accept the restrictions on physical activities such as swimming, bathing, recreational outdoor activities, working, exercising, contact with animais, etc. and the durations of these restrictions. -I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA). -I am aware that some products and tools used on the procedure site have not been approved by the federal Food and Drug Administration, and that the consequences of using these products are unknown. -I am aware of the signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of the procedure site, elevated body temperature, or purulent drainage from the procedure site. -I understand there is always a possibility of getting an infection as a result of receiving body piercing, particularly in the event that I do not take proper care of the procedure site. -I will seek professional medical attention if signs and symptoms of infection occur. -I have had opportunity to read and understand the documents presented to me. -I have had opportunity to ask questions about the procedure and all questions have been answered to my satisfaction. -I have been provided written aftercare instructions and understand them fully -I agree to release and forever hold harmless Silver Eagle Tattoo and its associates, agents, officers and shareholders from any and all claims, damages, or legal actions arising from, or connected in any way, with my tattoo or the procedures and conduct used to apply my tattoo, and any and all tattoos applied by Silver Eagle Tattoo and its associates, agents and representatives in the future.