RELEASE OF LIABILITY AND OF ALL CLAIMS
               - PLEASE READ CAREFULLY -

I UNDERSTAND THAT ANY PIERCING COULD RESULT IN SERIOUS INJURY, OR EVEN 
CONTRIBUTE TO MY DEATH.

I UNDERSTAND THAT IF MY BODY PIERCING BECOMES INFECTIOUS IN ANY POSSIBLE 
WAY, I HEREBY ASSUME ALL RISKS FOR THESE ACTIONS OR SITUATIONS.

I, _______________________ , ON THIS ____ DAY OF ________________, 20_______ 
HEREBY TAKE ACTION FOR MYSELF, MY EXECUTORS, ADMINISTRATORS, HEIRS, NEXT OF 
KIN, OR SUCCESSORS, AND WAIVE, RELEASE, DISCHARGE, AND AGREE NOT TO SUE, FOR 
ANY AND ALL LIABILITIES, INCLUDING MY DEATH, DISMEMBERMENT, DISABILITY, 
PERSONAL INJURY, OR CLAIMS OF ANY KIND WHICH MAY HERE AFTER OCCUR TO ME AS A 
RESULT OF MY PARTICIPATION IN ANY BODY PIERCING.

IN THIS GENERAL RELEASE, I REALIZE THAT I AM RELEASING CLAIMS OF ALL KINDS 
INCLUDING, BUT NOT LIMITED TO, (THOSE RESULTING FROM ANY OF THE CONDITIONS 
LISTED IN THE ABOVE AND BELOW PARAGRAPHS OF THIS RELEASE, AND INCLUDING) 
CLAIMS RESULTING FROM POOR SANITATION HABITS, STERILIZATION PROCEDURES, 
OPERATION-KNOWLEDGE, PROCEDURES, CONDITIONS, AND MALPRACTICE.  

THIS RELEASE APPLIES TO THE FOLLOWING PERSONS AND ENTITLES THOSE THAT MAY 
WORK AS AN AGENT, DIRECTOR, REPRESENTATIVE, EMPLOYEE, OR UNPAID VOLUNTEER, 
OF "PIERCEDFLESH.COM"  THIS RELEASE FURTHER
APPLIES TO ALL WRITTEN AND OR PRINTED MEDIA ADVERTISEMENTS.

IN ADDITION TO THIS RELEASE SET FORTH ABOVE, I AGREE TO INDEMNIFY AND HOLD 
HARMLESS THE PERSONS AND ENTITIES MENTIONED ABOVE FROM ANY AND ALL LIABILITIES
OR CLAIMS MADE BY OTHER INDIVIDUALS OR ENTITIES AS A RESULT OF ANY OF MY 
ACTIONS DURING, AND AFTER ANY PIERCING PROCEDURES OR SERVICES.

I HEREBY CERTIFY THAT I AM PHYSICALLY FIT AND THAT I FEEL SUFFICIENT TO HAVE 
THIS PIERCING SERVICE PERFORMED.

I AM NOT A DIABETIC, I AM NOT A HEMOPHILIAC.  I HAVE NO LUMPS, SWELLING OR ANY
OTHER SIGNS OF IRRITATION OF THE BODY, AND ONCE AGAIN CONSIDER MYSELF HEALTHY
ENOUGH TO REQUEST THIS PIERCING SERVICE.

I HAVE READ THE FOREGOING RELEASE AND WAIVER OF ALL CLAIMS, AND COMPLETELY 
UNDERSTAND ITS CONTENTS.

AS OF JANUARY 1ST 1998, A NEW LAW REQUIRES MINORS AND/OR PEOPLE UNDER 18 YEARS
OF AGE TO HAVE A SIGNATURE OF CONSENT AND/OR NOTIFICATION BY A PARENT OR LEGAL
GUARDIAN OLDER THAN 18 YEARS OF AGE, IN ORDER TO UNDERGO ANY BODY PIERCING SERVICE.

I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION SET FORTH HEREIN IS 
TRUE AND CORRECT.

I UNDERSTAND THAT THIS PIERCING TAKES _________________________ TO HEAL.


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ADDRESS                                  PHONE/FAX/PAGER