COVID-19 RELEASE FORM QUESTIONS

    I Understand - To prevent the spread of contagious viruses and to help protect others, 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

    I Confirm - that I am not presenting any of the symptoms of COVID-19 including

    • • dry cough

    • • running nose

    • • sore throat

    • • shortness of breath

    • • loss of sense of taste or smell

    • • fever

    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.

    What to Know Before Getting a Piercing

    Any piercing can be a very dangerous procedure if not done properly in a safe, clean environment by a trained professional. The responsibility lies upon you to research and ask questions about your body piercer and your specific body piercing. Some of the risks can include but are not limited to:

    Bloodborne disease: If the equipment used to do your piercing is contaminated with the blood of an infected person, you can contract a number of serious bloodborne diseases. These include, hepatitis C, hepatitis B, tetanus and HIV, the virus that causes AIDS.
    Allergic reactions: Some piercing jewelry is made of nickel or brass, which can cause allergic reactions.
    Oral complications. Jewelry worn in tongue piercings can chip and crack your teeth and damage your gums. Also, tongue swelling after a new piercing can block the throat and airway.
    Skin infections: Piercings may cause redness, swelling, pain and pus-like discharge.
    Scars and keloids: Body piercing may cause scars and keloids (ridged, raised areas caused by overgrowth of scar tissue).
    Tearing or trauma: Jewelry can get caught and torn out accidentally. Trauma to a piercing may require surgery or stitches to repair. If not repaired, the damaged area may develop permanent scars or deformity.

    Additional topics to discuss with your body art professional include their Bloodborne Pathogen Training, the establishment’s proficiency requirements, and the establishment’s autoclave monthly spore test results.

    If abnormal itching, irritation, redness, swelling or fever should appear please, contact a physician/dentist (for oral piercings) immediately. These could be signs of potentially serious medical condition that should be addressed.

    To ensure that your body art procedure heals properly, we ask that you disclose if you have or have had any of the following conditions. Disclosure does not legally prevent you from having a body art procedure.

    YesNo *Diabetes
    YesNo *History of hemophilia (Bleeding)
    YesNo *History of skin diseases, skin lesions, or skin sensitivities to soaps, disinfectants, etc.
    YesNo *History of allergies or adverse reactions to pigments, dyes or other skin sensitivities such as latex
    YesNo *History of epilepsy, seizures, fainting or narcolepsy
    YesNo *Use of medications, such as anticoagulants that thin the blood and/or interfere with blood clotting
    YesNo *Human immunodeficiency virus (HIV)
    YesNo *Hepatitis

    *I give UpRise Tattoos permission to take photos and post them online.
    YesNo

    *I understand that getting any piercing will not cure migraines/headaches or any other type of medical condition.
    YesNo

    Are you currently pregnant?
    YesNoN/A

    I understand that I cannot submerge/swim for the first 8 weeks of healing.
    YesNo

    ORAL PIERCING DECLARATION as required by the Criminal Code (720 ILCS 5/12-10.1) It is understood that the oral piercing of the tongue, lips, cheeks, or any other area of the oral cavity carries serious risk of infection or damage to the mouth and teeth, or both infection and damage to those areas, that could result but is not limited to nerve damage, numbness, and life threatening blood clots.

    *Are you 18 years or older?:

    Parent First and Last Name:

    Client Birthdate:

    *Client Full Name:

    *Client Phone: Example: 8475551234

    *Client Email:

    *By selecting the "I Accept" button, you are signing this Agreement electronically. Your electronic
    signature is the legal equivalent of your manual/handwritten signature on this Agreement.
    I Accept

    *Client Picture ID: If the client is younger than 18 years old, a parent or legal guardian Identification must also be provided.
    Acceptable Identification: Passports, Driver's licenses, or state ID cards for non-drivers, issued by a state's Department of Motor Vehicles. we can not accept a military ID due to the fact that we must attach a photo to your release form. Replicating a military ID (which belongs to the federal government) is prohibited.

    *Client Picture ID:

    Congrats! You finished filling out your portion of the release form! Please allow an UpRise Employee to complete the remainder of the form.

    *Date:

    *Piercer Name:

    *Piercing Type:

    *Integrator Number: