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PARENTAL CONSENT FOR BODY PIERCING ON A MINOR
PiercedFlesh Studios
73 Dingley Road Carmel, NY 10512 (Putnam County)

I understand that the PIERCEE will be pierced under proper conditions with instruments, tools, and techniques designed specifically for body piercing. I understand that the PIERCEE will be pierced with pre-sterilized needle, used only on the PIERCEE and then immediately disposed of. Most materials that we use for the procedure are single-use and get thrown away after each person. Those tools that are re-used are subject to ultrasonic cleaning and autoclaving before re-use.

I acknowledge that infection is always a possible result of a new piercing, and understand that following the verbal and written aftercare instructions the PIERCEE will be provided with will increase the chances of successful healing. I acknowledge that it is not reasonable possible for the piercer to determine whether or not the PIERCEE may experience an allergic reaction to the piercing jewelry or the materials used in the procedure. I will advise the piercer of any known allergies or physical conditions, immunosuppressive illnesses, epilepsy, diabetes, or tendency to keloid, that the PIERCEE suffers from and have been advised of any special precautions to take during the healing.

I understand that PiercedFlesh Studios reserves the right to refuse service to anyone for any reason. Additionally, PiercedFlesh Studios reserves the right to decline to perform certain piercings on any individual at the discretion of the piercer on duty. PiercedFlesh Studios will not perform nipple or genital piercings on minors under any circumstances.

PARENTAL/MANAGING CONSERVATOR/GUARDIAN INFORMATION:

           INIT:______ I CONFIRM THAT I HAVE READ THIS FORM, THAT I UNDERSTAND IT, AND AGREE TO BE LEGALLY BOUND TO IT.

           INIT:______ I have provided VALID STATE OR FEDERAL GOVERNMENT ISSUED PHOTO IDENTIFICATION as proof of my identity.

           INIT:______ I have presented evidence of my status as PARENT, MANAGING CONSERVATOR, OR LEGAL GUARDIAN of the individual to be pierced.

           INIT:______ I have presented VALID STATE OR FEDERAL GOVERNMENT ISSUED PHOTO IDENTIFICATION as proof of the identity of the individual to be pierced.

           INIT:______ I induce PiercedFlesh Studios and its representatives to perform the body piercing described in this document upon the person described in this document as the PIERCEE, and in consideration for doing so, release PiercedFlesh Studios and its representatives from all liability.

PIERCING TO BE PERFORMED (CIRCLE ONE ONLY. A SEPARATE FORM MUST BE COMPLETED FOR EACH PIERCING):

NAVEL - TONGUE - NOSTRIL - SEPTUM - EYEBROW - LIP - EARLOBE - EAR (OTHER) - OTHER ___________________

PRINTED NAME OF GUARDIAN: ______________________________________________________________________
ADDRESS: ____________________________________________________________________________________________
CITY: _________________________________________ STATE: __________________ ZIP: _____________________
PHONE: (________)_________________________ E-MAIL (IF AVAILABLE): ___________________________________
ID NUMBER: _________________________ ID TYPE: ______________ EXPIRES: _____________ DOB: ____________

SIGNATURE: ____________________________________________________________________ DATE: _______________

MINOR/PIERCEE INFORMATION:
PRINTED NAME OF MINOR/PIERCEE: ______________________________________________________________________
ADDRESS: ____________________________________________________________________________________________
CITY: _________________________________________ STATE:___________________ ZIP: _____________________
PHONE: (________)______________________ E-MAIL (IF AVAILABLE): ______________________________________
ID NUMBER: ____________________________ ID TYPE: ______________ EXPIRES: ____________ DOB: __________

SIGNATURE: ____________________________________________________________________ DATE: _______________

NOTARY INFORMATION
NOTARY NAME: _______________________________________________________________________________________
ADDRESS: ______________________________________ CITY: _________________ STATE: _____ ZIP: _________
PHONE: ______________________________________ NOTARY STAMP # _______________________________________

THIS FORM MUST BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC AND NOTARIZED.
THIS DOCUMENT REMAINS THE PROPERTY OF PIERCEDFLESH STUDIOS AND PIERCEDFLESH.COM
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Copyright 2001-2017, PiercedFlesh Studios
73 Dingley Road
Carmel, NY 10512 (Putnam County)
845-721-7490
T/Th/F 9am - 1pm EST

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