Minor Consent Form

Thank you for choosing Laughing Buddha for your piercing today. Please have the minor’s original birth certificate, minors photo ID, and parent/legal guardian ID handy and complete the following form. For security, the contents of your submission will be emailed to our staff and not stored on our web server.

What name would you like us to call you (the minor)?

Enter the minor's full legal name:

Enter the minor's date of birth (MM-DD-YYYY):

What piercing are you getting today?

PARENT/GUARDIAN: Enter your full legal name:

Consent

I, the undersigned Parent/Guardian of the undersigned minor hereby consent to the specified piercing, to be conducted by Laughing Buddha, or any agent or employee of the same as follows:

I acknowledge by signing this release that I have been given full opportunity to ask any and all questions that I may have and that all my questions have been answered to my full and total satisfaction. To endure the efficiency of healing, I will inform Laughing Buddha of any conditions, medical or otherwise, which may impair the full and proper healing of my piercing.

1. We have valid legal photographic identification in the form of a United States driver
License, State identification card, Military identification, passport or other as well as the minors birth certificate, proving the minors age and relationship to parent/guardian and that we have exhibited said identification to Laughing Buddha prior to being pierced.

Please specify what proof of ID you are providing (ONLY if NOT a United States driver
License, State identification card, Military identification, or passport.)

2. We fully understand, acknowledge and agree that Laughing Buddha is not and shall not act in the capacity of a health care provider or medical professional with respect to the piercing or any aftercare provided.

3. We fully understand there will be physical limitation on certain activities during healing such as bathing, recreational water activities, gardening, and contact with animals for a period of time.

4. We acknowledge and understand that by having this piercing performed I am making a permanent change to my body which cannot be undone. I further acknowledge and understand that there have been no claims or guarantees made about the ability to undo any of the permanent changes that I have consented to be made by this piercing.

5. We will follow the written and oral aftercare instructions and procedures outlines and provided to me until the healing of the piercing is complete.

6. We will seek professional medical attention in case the following signs and symptoms of infection should occur, including but not limited to; redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent (pus) drainage from the procedure site.

Medical Questionnaire

The following medical questions are confidential, and solely used by the staff at Laughing Buddha Body Piercing to ensure the procedure is being performed safely.

1. Have you taken any alcohol or narcotics today?

YESNO

2. Are you pregnant or breastfeeding?

YESNO

3. Do you have any illness which weakens the immune system?

YESNO

4. Do you have a history of herpes at procedure site or diabetes?

YESNO

5. Do you have a history of medication use, or are you currently using any medication (including antibiotics)?

YESNO

6. Do you have any condition, or take any medication which thins the blood (e.g. high blood pressure, hemophilia)?

YESNO

7. Are you vegan or vegetarian?

YESNO

8. Are you prone to excessive bleeding?

YESNO

9. Are you prone to excessive scarring?

YESNO

10. Do you have any metal, latex or soap allergies?

YESNO

11. Have you had this exact piercing done before (i.e. is this a repiercing)?

YESNO

12. Do you have a fever, cough, body aches, shortness of breath?

YESNO

COVID-19 RELEASE

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact.

The Empire Inc./ Laughing Buddha Body Piercing (“the Facility”) has put in place preventative measures to reduce the spread of COVID-19; however, infection from COVID-19 can happen anywhere and no business can guarantee or completely prevent someone from becoming infected. Further, being in any business could increase your risk of contracting COVID-19.

1. To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facility’s guidelines. The facility’s guidelines can be changed at anytime as new information and technology become available. To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow the facility’s guidelines. The facility’s guidelines can be changed at anytime as new information and technology become available.

2. I confirm that I am not presenting any of the symptoms of COVID-19 including:

dry cough
runny nose
sore throat
shortness of breath
loss of sense of taste or smell
fever

3. I confirm that I have not been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days.

4. I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have not traveled outside of or domestically within the [nation OR region] in the past 14 days.

Identification

PARENT/GUARDIAN: Please provide a copy of your ID. You can take a picture with your phone and attach the image here.

MINOR: Please provide a copy of your ID.

Please provide a copy of MINOR's Birth Certificate.

The undersigned for himself or herself, the heirs, successors, representatives as assigns hereby forever waives releases and discharges Laughing Buddha Body Piercing, their agents, employees, representatives, and other organizations affiliated with this studio and any and all of their heirs, successors or assigns (hereinafter referred to as Releasees.)

The undersigned further agrees to indemnify and do indemnify the Releasees from any and all claims demands, actions, liability and/or damages whatsoever performed under this agreement. The indemnification shall include, but shall not be limited to any and all attorney fees and costs incurred.

Minor Consent Form

Consent

Medical Questionnaire

COVID-19 RELEASE

Identification

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