I hereby give my consent to body piercer. I fully understand that the Piercer does not act as a medical professional and that any suggestions or statements made to me by the Piercer are not to be construed as or substituted for medical advice or instruction. I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about obtaining a body piercing from Authentic Arts Tattoo & Gallery and its employees and all my questions have been answered to my full and total satisfaction. I acknowledge I have been advised of the matters set forth below and I agree as follows:

1. I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take medication which thins the blood. I have informed the Piercer of any condition such as diabetes that might hamper healing of the piercing.

2. If I suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advised of any procedures necessary to promote the satisfactory healing of my piercing.

3. I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.

4. I have advised the Piercer of any allergies that I might have to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.

5. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well­-being as a direct or indirect result of my decision to have a piercing done at this time.

6. I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my child’s appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre­piercing condition.

7. I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and we agree to follow all of them while my piercing is healing.

8. THE SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES DOES NOT ENDORSE OR RECOMMEND BODY ART PROCEDURES IN ANY FORM. The Piercer stated hereon has fully explained to me the nature of the procedure(s) and has informed me of the potential complications and risks including, but not limited to: bleeding, pain, swelling, infection, prolonged healing, scarring, nerve damage, fainting and death.

9. I acknowledge that I am being pierced under proper sterile conditions I am aware that Body Art Procedures are invasive and may involve possible health risks, especially for people with certain underlying medical conditions. I am also aware that I should consult with my physician prior to receiving any Body Art Procedure. If I experience an adverse effect during the healing period related to the Body Art Procedure that I received, I have been advised to seek medical care as soon as possible and advise the Body Artist and/or the Body Art Establishment where I received the procedure.

*NOTE: It is possible to become infected with Hepatitis B, Hepatitis C, HIV or any other blood­borne disease with any procedure that involves exposure to blood products or instruments contaminated with blood products. In addition, an individual cannot donate blood for 12 months after having any body art procedure.

I have been provided with a copy of Aftercare Instructions and Notice Regarding Healing Periods for my child’s particular Body Art Procedure. We have also had the opportunity to have any questions about the procedure answered.

By agreeing I also certify that the body piercing work has been completed to my satisfaction.