American Gypsy Tattoo Company

Piercing Release and Medical Disclosure

First name

Last name

Age

Birthday

Race

Sex

Lisy any allergies, including allergies to medications, topical solutions, and foods.

History of bleeding disorders?

yes

If you answered "yes" to the above question, please explain:

Have you ever been diagnosed with a communicable disease?

yes

Are you currently under treatment for any infectious disease?

yes

If you answered "yes" to either of the two questions above, please explain:

Are you currently pregnant or do you suspect you might be pregnant?

yes

Please, initial below that you have read, understand, and agree to the following statements:

I acknowledge and understand that I will be pierced using sterilized instruments and appropriate techniques.

I acknowledge and understand that infection is always possible as a result of obtaining a piercing.

I certify that I will follow all after care instructions given to me by the piercer to the best of my ability, for the entire duration of the healing process.

I acknowledge and understand that this piercing is a permanent change to my physical appearance.

Liability Release Statement

I, hereby acknowledge that I am voluntarily requesting a piercing from American Gypsy Tattoo Company. I understand that piercing involves the insertion of jewelry into the body and carries inherent risks, including but not limited to infection, allergic reactions, scarring, and migration of the jewelry.

I have carefully considered the risks associated with piercing and agree to assume full responsibility for any complications or adverse reactions that may arise. I release American Gypsy Tattoo Company, its employees, and agents from any and all liability for any injuries, damages, or complications resulting from the piercing procedure.

I certify that I am of legal age to consent to this procedure and that I am not under the influence of alcohol or drugs. I have provided accurate and complete medical information to the piercer.

I acknowledge that American Gypsy Tattoo Company will be performing the piercing using appropriate instruments and techniques as per Florida State regulations and guidelines.

I understand that proper aftercare is essential for the healing process and agree to follow the aftercare instructions provided by American Gypsy Tattoo Company.

By signing below, I affirm that I have read and understood this liability release and agree to its terms.

Signature

Please select your piercing professional:

Body Part Pierced:

Date