PIERCINGS BY SHOSHANNA EAR PIERCING RELEASE AND AUTHORIZATION FORM

Name of Client Being Pierced _____________________________________________________________ Date ______________

Client Address ___________________________________________________________________________________________

Cellphone Number ____________________________ ALLERGIES __________________________________________________

CURRENT AGE OF CHILD ______ DOB ______ EARLOBE __________ CARTILAGE __________ EARING STYLE NUMBER ________

IN SIGNING THIS RELEASE AND AUTHORIZATION, I ACKNOWLEDGE AND REPRESENT THAT:

A) I HAVE READ THIS RELEASE FORM I UNDERSTAND IT AND SIGN IT VOLUNTARILY.

B) I ACKNOWLEDGE RECEIPT OF AND UNDERSTAND THE AFTERCARE INSTRUCTIONS AND THE RISK OF INFECTION, I UNDERSTAND THAT I MUST CAREFULLY FOLLOW ALL AFTERCARE INSTRUCTIONS.

C) IF HAVING MY CARTILAGE PIERCED, I ACKNOWLEDGE THAT I AM FULLY AWARE THAT CARTILAGE PIERCING MAY CARRY A GREATER RISK OF INFECTION/COMPLICATION DUE TO IMPROPER CARE OF MY PIERCED EARS. SHOULD A PROBLEM OCCUR, I SHOULD SEEK MEDICAL ATTENTION IMMEDIATELY.

D) I UNDERSTAND IF I AM TAKING BLOOD THINNING MEDICATIONS, HAVE DIABETES, MAY BE PREGNANT OR HAVE A MEDICAL PROBLEM OR HISTORY, I SHOULD OBTAIN A DOCTOR'S APPROVAL BEFORE A PIERCING IS PERFORMED. PREGNANT WOMEN USUALLY CANNOT INGEST MEDICATION SHOULD AN INFECTION OCCUR.

I CERTIFY THAT I CONSENT TO HAVE MY EAR(S) PIERCED BY PIERCINGS BY SHOSHANNA LLC. I ASSUME ALL RESPONSIBILITY FOR INJURY OR LOSS OF ANY KIND THAT MAY BE ASSOCIATED WITH THIS EAR-PIERCING PROCEDURE AND AGREE TO RELEASE AND HOLD HARMLESS PIERCINGS BY SHOSHANNA LLC AND INVERNESS FROM ANY AND ALL ACTIONS AND LIABILITY RESULTING FROM OR RELATING TO THIS EAR PIERCING(S).

PHOTOGRAPHIC RELEASE: I GRANT PERMISSION AND CONSENT TO PIERCINGS BY SHOSHANNA FOR USE OF A CLOSE-UP PHOTOGRAPH OF THE PIERCING FOR PRESENTATION UNDER ANY LEGAL CONDITION INCLUDING PUBLICITY ADVERTISING MARKETING AND WEB CONTENT. I UNDERSTAND THERE SHALL BE NO PAYMENT OF ROYALTIES OR REVOCATION FOR THIS RELEASE.

OPT OUT OF PHOTOGRAPHIC RELEASE (CHECK HERE) □

IF UNDER 18 YEARS OF AGE PARENT OR LEGAL GUARDIAN SIGNATURE IS REQUIRED

I REPRESENT AND CERTIFY THAT I AM OVER 18 YEARS OF AGE OR IF GIVEN ON BEHALF OF A MINOR THAT I AM THE PARENT OR LEGAL GUARDIAN OF SUCH MINOR AND I WILL HOLD ONLY MYSELF LIABLE AND WILL INDEMNIFY, DEFEND AND HOLD HARMLESS PIERCINGS BY SHOSHANNA LLC AND INVERNESS IN THE EVENT SUCH MINOR MAKES A CLAIM AS A RESULT OF EAR PIERCING. I UNDERSTAND A MINOR SIGNING AS AN ADULT OR AN ADULT FALSIFYING INFORMATION CONSTITUTES A LEGALLY FRAUDULENT ACT.

SIGNATURE _____________________________________________________________________________________________

PRINTED NAME __________________________________________________________________________________________