NINA WYNN PIERCING WAIVER

Date of birth *

These Questions are required by the Denver Dept of Public Health & Environment

1. Are you over the age of 18?

Yes

2. Do you have a fever?

Yes

3. Do you have shortness of breath?

Yes

4. Do you have Diabetes? (This question is required by the overseeing licensure board

Yes

5. Do you have a seizure condition?

Yes

6. Have you ever been diagnosed with blood pressure problems?

Yes

7. Do you have skin surfaces that have sunburn, rash, pimples, jaundice, boils, infections, moles, or manifest any evidence of unhealthy conditions?

Yes

8. Do you have any skin diseases or skin lesions?

Yes

9. Do you have hemophilia?

Yes

10. Have you had any Allergies or adverse reactions to latex, pigments, dyes, disinfectants, soaps, or metals?

Yes

11. Have you received treatment with anticoagulants or other medications that thin the blood and/or interfere with blood clotting?

Yes

12. Have you ever had a piercing that required removal due to infection?

Yes

13.Text Do you have a History of epilepsy, seizures, fainting, or narcolepsy?

Yes

14. Have you eaten in the past 4 hours? Most people do better after eating a small meal.

Yes

15. Do you have any bloodborne pathogens such as Hepatitis or HIV, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for ours and others safety). HIV, transmittable diseases or recent illnesses? (It's okay if you do, we just want to know for ours and others safety).

Yes

Appointment Date *

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 restore the skin involved in this piercing to its pre-piercing condition.

I have trustfully represented to the Piercer that I am over the age of eighteen (18) years.

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about obtaining an ear or body piercing or microdermal (single point piercing) and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I am hereby advised of the facts and matters set forth below and I agree as follows:

If I suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advised of any procedures necessary to promote the satisfactory healing of my 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 do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, auricular chondritis, psoriasis at the site of the piercing or any open wounds, infections, rashes, or lesions at the site of the piercing I have selected.

I understand that piercings in the ear that are NOT in the lobe, for example, in the upper ear or cartilage usually take 6-9 months or longer to heal

I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.

I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take medication which thins the blood. I have informed my Piercer of any conditions such as diabetes or auto-immune disorders that might hamper the healing of the piercing.

I acknowledge infections and inflammation including auricular chondritis, is always possible as a result of obtaining a piercing. Comprehensive aftercare instructions have been made available to me and I agree to follow all of them while my piercing is healing.

I understand I will be pierced using appropriate instruments and sterilization.

I understand that Nina Wynn, Wynn Group LLC reserves all rights to use any photos or videos of my piercing taken.

I acknowledge that I have been given adequate opportunity to read and understand this document, and I understand that I am signing a legal contract.

I promise to consult a physician if I experience signs of an adverse reaction including infection, illness, allergic reaction or disease.

I understand that the piercer with their expertise and experience as well as my adherence to the Aftercare instructions will give me the greatest likelihood of a successful outcome.

I understand that piercings in the ear-lobe usually take 3 months for lobe and 10 months for Cartilage or longer to heal.

I understand that the possibility of a labret, or a piece of jewelry from the front of the piercing could embed itself into the skin requiring it to be excised either by the professional piercer or if need be a qualified physician. While rare, these instances can happen, especially with a forceful blow to the piercing.

I understand that I will need to downsize the gauge of my original piercing in 8 weeks for a lobe piercing and 9 months for a cartilage piercing following the original piercing in order to foster healing.

Tell your piercer if you have had any of the above or any other health related concerns whether physical or psychological that would aid the piercer to evaluate your potential to heal.

Piercing Release Form

I agree TO WAIVE AND RELEASE to the fullest extent permitted by law the Piercer and the Piercing Studio, Nina Wynn, Wynn Group LLC from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assignees may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise.

By signing below and submitting a photo with ID, I, ________________________ , (or their legal guardian), agree that I have read this Body Piercing Release form provided by Nina Wynn, Wynn Group LLC and agree to its terms.

Attach a copy of the client holding their driver's license or equivalent ID.

Clear

SIGN HERE

A copy of your aftercare and our contact is email and texting you.

Email: [email protected]

Phone: 720-594-5897