BodMod Shop Waiver of Claims

BodMod Shop

• 205 S Main St Canandaigua NY 14424 • 585·577·3311
Are you filling this out at our shop for a service that is being done today?*

YesNo
Date Form Completed

MonthDayYear
Date
Date of Future Service

MonthDayYear
Date of Service*

MonthDayYear
Date
Date of Birth of Person Receiving Service

MonthDayYear
Age
Artist

ranJoeOther
Artist Signature

Clear
Consultant

DBJoeranOther
Consultant Signature

Clear
18+

YesNo
Please take a photo of your ID
Please take a photo of Minor's ID
Please take a photo of Parent or Guardian's ID
Please take a photo of your Proof of Guardianship
Client Information
Participant's Name*

First NameLast Name
Minor's Name*

First NameLast Name
If your name/pronouns don't match your ID, you can inform us here if you wish.

NamePronouns
Parent / Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Requested Services
What Brings You Here Today?
Piercing
Tattoo
Which Piercing?
Ear
Nose
Septum
Oral
Eyebrow
Bridge
Navel
Microdermal
Nipples
Genital
Other
Which Other Piercing? *
Tattoo Concept and Location*

ConceptLocation
Informed Consent
A piercing is a permanent change to one's appearance and can be difficult to remove, can be disfiguring, and in all likelihood, removal will not result in the restoration of one's skin to its exact appearance before being pierced.

The risks of being pierced include but are not limited to: irritation, swelling, redness, infection (particularly if aftercare instructions are not followed), scarring, difficulties in diagnostic imaging, as well as allergic reactions to jewelry material, gloves, skin preparation compounds, marking inks and/or lubricants.

I fully understand that the risks inherent to being pierced, known and unknown, can lead to injury.
A piercing is a permanent change to one's appearance and can be difficult to remove, can be disfiguring, and in all likelihood, removal will not result in the restoration of one's skin to its exact appearance before being pierced.

The risks of being pierced include but are not limited to: irritation, swelling, redness, infection (particularly if aftercare instructions are not followed), scarring, difficulties in diagnostic imaging, as well as allergic reactions to jewelry material, gloves, skin preparation compounds, marking inks and/or lubricants.

I fully understand that the risks inherent to being pierced, known and unknown, can lead to injury.
A tattoo is a permanent change to one's appearance and can be difficult to remove, can be disfiguring, and in all likelihood, removal will not result in the restoration of one's skin to its exact appearance before being tattooed.

The risks of being tattooed include but are not limited to: irritation, swelling, redness, infection (particularly if aftercare instructions are not followed), scarring, difficulties in diagnostic imaging andor detection of skin condtions, as well as allergic reactions to needles, gloves, skin preparation compounds, tattoo pigments, marking inks and/or lubricants.

My reactions to being tattooed can and will affect the outcome of my finished art. The artist will do everything in their power to work around this, but I understand that a perfect tattoo is impossible on a moving body. I will let my artist know if I am too uncomfortable / in too much pain to continue remaining still, and we will reschedule or cancel the rest of the tattoo, with no refund available for any payment already made.

I fully understand that the risks inherent to being tattooed, known and unknown, can lead to injury.
Piercing-Specific Caveats

IMPORTANT - PLEASE READ
Oral Piercings carry the added risk of damage to teeth and tissues of the mouth, as well as difficulties eating and/or speaking. Oral Piercings carry the added risk of damage to teeth and tissues of the mouth, as well as difficulties eating and/or speaking.
Cheek piercings can permanently affect salivary glands due to placement, and do affect the muscles of the cheek - usually leading to permanent "dimples".
Frenulum Piercings carry a higher risk of tearing/migration due to the tissues involved.
Horizontal Tongue Piercings WILL cause broken/cracked/chipped teeth, is very likely to cause gum/enamel erosion, and may cause difficulties with normal tongue functions - including, but not limited to - eating and speaking.

We strongly discourage you from continuing with this piercing.
Microdermals and Surface Piercings carry a higher risk of migration or rejection. They also present unique difficulties in removal, most often requiring removal by a professional.
The BodMod Shop and/or its agents will give me instructions on the care of my tattoo and piercing while it's healing, I will ask for clarification until I understand them, and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any work for the tattoo or piercing is needed due to my own negligence, I agree that the work will be done at my own expense.

I understand that The BodMod Shop and all of its agents have taken all precautions in their power to mitigate said risks, I agree to do the same while caring for my tattoo and piercing, and I understand that I can contact The Bodmod Shop or one of its agents for assistance in the aforementioned.

Neither the BodMod Shop nor its agents are responsible for any meaning that can be assigned to, the suitability for work or sport of, nor the effects on employability nor job status of the placement, jewelry or design that I have chosen.

Variations in anatomy may lead to variations in jewelry, color, details and placement between the design I have selected and the finished piercing/tattoo when it is on my body.

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be pierced and tattooed by the Artist without duress or coercion.
The BodMod Shop and/or its agents will give me instructions on the care of my tattoo while it's healing, I will ask for clarification until I understand them, and will follow them. I acknowledge that it is possible that the tattoo can become infected, particularly if I do not follow the instructions given to me. If any work for the tattoo is needed due to my own negligence, I agree that the work will be done at my own expense.

I understand that The BodMod Shop and all of its agents have taken all precautions in their power to mitigate said risks, I agree to do the same while caring for my tattoo, and I understand that I can contact The Bodmod Shop or one of its agents for assistance in the aforementioned.

Neither the BodMod Shop nor its agents are responsible for any meaning that can be assigned to, the suitability for work or sport of, nor the effects on employability nor job status of the placement or design that I have chosen.

Variations in anatomy may lead to variations in color, details and placement between the design I have selected and the finished tattoo when it is on my body.

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be tattooed by the Artist without duress or coercion.
There are many medical / psychological conditions and medications that can affect the piercing procedure and/or the healing of my piercing. These include, but are not limited to:

General Illness
Diabetes
Epilepsy
Hemophilia / Blood thinning medications
Heart Conditions not limited to Mitral Valve Prolapse
Skin Conditions not limited to Psoriasis
Organ / Bone Marrow / etc. Transplant
Pregnancy
Mental Conditions or Medications that can affect judgment
There are many medical / psychological conditions and medications that can affect the piercing/tattooing procedure and/or the healing of my piercing/tattoo. These include, but are not limited to:

General Illness
Diabetes
Epilepsy
Hemophilia / Blood thinning medications
Heart Conditions not limited to Mitral Valve Prolapse
Skin Conditions not limited to Psoriasis
Organ / Bone Marrow / etc. Transplant
Pregnancy
Mental Conditions or Medications that can affect judgment
There are many medical / psychological conditions and medications that can affect the tattooing procedure and/or the healing of my tattoo. These include, but are not limited to:

General Illness
Diabetes
Epilepsy
Hemophilia / Blood thinning medications
Heart Conditions not limited to Mitral Valve Prolapse
Skin Conditions not limited to Psoriasis
Organ / Bone Marrow / etc. Transplant
Pregnancy
Mental Conditions or Medications that can affect judgment
Regarding the previous paragraph, please check any and all options below that apply to you.*

None of the above apply to meI prefer not to discussI will discuss with my artist(s)I have been cleared by my doctor for this procedure and/or I have taken all medication prescribed by my doctor for use before invasive procedures
Model Release (OPTIONAL)

I release all rights to any photographs or video taken of me and/or my piercings/tattoos and give consent in advance to their reproduction in print or electronic form.
Having been informed of the potential risks associated with being pierced, I still wish to proceed with the piercing procedure and I freely accept and expressly assume any and all risks that may arise from being pierced.
Having been informed of the potential risks associated with being tattooed/pierced, I still wish to proceed with the tattooing/piercing procedure, and I freely accept and expressly assume any and all risks that may arise from being tattooed/pierced.
Having been informed of the potential risks associated with being tattooed, I still wish to proceed with the tattooing procedure, and I freely accept and expressly assume any and all risks that may arise from being tattooed.
I release to the fullest extent permitted by law The BodMod Shop and its agents from all liability whatsoever, and waive my rights for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise. This includes any direct and/or consequential damages, which result or arise from the application of my piercing, whether caused by the negligence or fault of either the Artist or the Studio, or otherwise.

I agree to reimburse each of the Artist and the Studio for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or the Studio and in which either the Artist or the Studio is the prevailing party. I agree that the court of NY and that the courts of Ontario County shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for the purpose of litigating any dispute arising out of or related to this agreement.

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute or after the fact, and I understand that I am signing a legal contract waiving certain rights to recover against the Artist and the Studio.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
I hereby declare under penalty of perjury that I am of legal age (I have provided valid proof of identity and age) and I am competent to sign this Agreement.
I hereby declare under penalty of perjury that I am the parent or legal guardian of the minor requesting this piercing (and have provided valid proof of identity and guardianship) and am competent to sign this Agreement on behalf of my child.
I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT
Signature*

Clear
Parent/Legal Guardian Signature

Clear
In consideration of the above statements, I hereby request the aforementioned piercing.
Minor Signature

Clear

The BodMod Shop and its agents will give me instructions on the care of my piercing while it's healing, and I will ask for clarification until I understand them, and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. If any work for the piercing is needed due to my own negligence, I agree that the work will be done at my own expense.

I understand that The BodMod Shop and all of its agents have taken all precautions in their power to mitigate said risks, I agree to do the same while caring for my piercing, and I understand that I can contact The Bodmod Shop or one of its agents for assistance in the aforementioned.

Neither the BodMod Shop nor its agents are responsible for any meaning that can be assigned to, the suitability for work or sport of, nor the effects on employability nor job status of the placement or jewelry that I have chosen.

Variations in anatomy may lead to variations in jewelry and placement between the piercing I have selected and the actual piercing when it is on my body.

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be pierced by the Artist without duress or coercion.
NYS DOH 5072
Parent or Legal Guardian Consent for Body Piercing of a Person Under 18 Years of Age

NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection
Health Risk Awareness
It is important to be aware of the potential health risks associated with body piercing such as allergic reactions, skin infections, hepatitis, prolonged bleeding, swelling, scarring and general discomfort. Existing medical conditions such as allergies, heart disease, diabetes, skin disorders or conditions that affect the immune system may increase the risk of complications from body piercing. Before providing consent for body piercing, speak with a physician regarding potential health risks for your child.
Body Piercing Consent Requirements
New York State Public Health Law Article 4-A, Section 460-a, prohibits the owner, operator or employee of a body piercing studio from body piercing a person under eighteen years of age unless a parent or legal guardian provides written consent. To provide consent, the parent or legal guardian must complete and sign this form in the presence of the owner of the body piercing studio or in the presence of the studio's body piercing specialist. The original written consent will be retained by the body piercing studio and will expire twelve months from the date it was signed.
Studio
Name*
Address*
City*
State*
Zip Code*
Name of Legal Operator*
Name of Body Piercing Specialist*
Parent/Legal Guardian
I, (Print name of parent or legal guardian)*

First NameLast Name
am the parent or legal guardian of (Print the name of the minor)*

First NameLast Name
Born on*

MonthDayYear
Date
I give consent to the owner of this body piercing studio and/or the body piercing specialist named above, to body pierce my child who is under the age of eighteen years of age. This consent is limited to the following type(s) and location(s) of body piercing(s):*
Clear
Parent / Legal Guardian's Signature
Studio Owner or Body Piercing Specialist
Signature of the studio owner or body piercing specialist:

Clear
owner or body piercing specialist of the studio named above, attest that the above named parent or legal guardian signed this form in my presence on:
MonthDayYear
Date
Should be Empty:

BodMod Shop

Client Information

Requested Services

Informed Consent

Piercing-Specific Caveats

NYS DOH 5072

Parent or Legal Guardian Consent for Body Piercing of a Person Under 18 Years of Age

Health Risk Awareness

Body Piercing Consent Requirements

Studio

Parent/Legal Guardian

Studio Owner or Body Piercing Specialist