Rowan Ear Piercing and Aftercare Release and Consent Form

EAR PIERCING AND AFTERCARE WAIVER, RELEASE AND CONSENT AGREEMENT

If the individual upon whom the piercing is being performed (the “Customer”) is under the age of 18, this form must be completed and signed by a parent or legal guardian of the Customer.

1. Customer Information

(See below)

Note: Rowan reserves the right to refuse to perform body art on any minor at any time and for any reason, regardless of the provision of parental consent.

  2. Disclosures, Agreements, Acknowledgments & Release Health Risk Advisory

I understand that there are inherent health risks associated with ear piercing including, but not limited to, allergic reactions, skin infections, tissue damage, nerve damage, prolonged bleeding, swelling, hypertrophic scarring, a decreased ability of physicians to locate skin melanoma in regions concealed by body art, febrile illness, tetanus, systemic infection, keloid formation, pain and general discomfort.  Such complications may occur at the location of the piercing or elsewhere on the body.  There are increased risks for adolescents during certain stages of development.  Additionally, existing medical conditions, or a history of certain medical conditions, such as allergies; heart disease; diabetes; hemophilia (bleeding); skin disorders; skin disease; skin lesions; skin sensitivities to soaps, disinfectants, etc.; skin cancer; allergies, anaphylactic reaction, or other adverse reaction to pigment, dyes, or other sensitivities; epilepsy, seizures, fainting, or narcolepsy; peripheral nerve disease; any deficiency of the immune or circulatory system; use of medications such as anticoagulants, which thin the blood or interfere with blood clotting; hepatitis; HIV; a history of infection; pregnancy; conditions that affect the immune system; or any other known or unknown medical condition may increase the risk of complications from ear piercing.  I hereby represent that I have been advised to consult with a physician prior to the procedure if the Customer falls into any of the above heightened risk categories; and that I have consulted with a physician regarding any concerns I may have regarding the potential health risks that obtaining the above-described piercing may pose to the Customer. NOTWITHSTANDING THESE RISKS, I ACKNOWLEDGE THAT I AM VOLUNTARILY CHOOSING TO PROCEED WITH THE PIERCING PROCEDURE WITH KNOWLEDGE OF THE RISKS INVOLVED. 

For Alameda County, California Customers Only:  Pursuant to local law, no body art procedures will be performed on any individual with any of the following health conditions:   diabetes; a history of hemophilia; a history of skin disease, skin lesions, or skin sensitivities to soap or disinfectants; a history of allergies to metals; a history of epilepsy, fainting, or narcolepsy; a condition for which the client takes medications, such as anticoagulants, that thin the blood and/or interferes with blood clotting; or any evidence of any unhealthy medical condition without the written clearance by a physician licensed under the Business and Professions Code § § 2000 et seq..  By proceeding with this piercing procedure, you expressly agree that you do not have any of the aforementioned health conditions.

For Fulton County and Minnesota Customers Only: I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing without duress or coercion. 

For Illinois, Louisiana, Cambridge County, Massachusetts, Minnesota, and South Carolina Customers Only:  To ensure that your body piercing procedure heals properly, we ask that you disclose if you have or have had any of the following conditions.  Disclosure does not prevent you from having a body art procedure. (a) Diabetes; (b) History of hemophilia (bleeding); (c) history of skin diseases, skin lesions or skin sensitivities to soaps, disinfectants, etc.; (d) history of allergies or adverse reactions to pigments, dyes or other skin sensitivities such as, but not limited to, latex or metals; (e) history of epilepsy, seizures, fainting or narcolepsy; (f) Medications used, such as anticoagulants that thin the blood and/or interfere with blood clotting; (g) Human immunodeficiency virus (HIV); (h) Hepatitis; (i) pregnancy or breast-feeding/nursing; (j) immune disorders; (k) history of scarring or keloid formation; or (l) any other information that would aid us in evaluating your body art healing process.

For Burlington, MA:
BODY PIERCING DISCLOSURE STATEMENT

THIS STATEMENT IS TO BE GIVEN TO ALL BODY ART CLIENTS, AND IS TO BE SIGNED
BY THE CLIENT, PRIOR TO PERFORMING ANY BODY ART PROCEDURE

• As with any invasive procedure, body piercing may involve possible health risks.
  These risks may include: Pain, bleeding, swelling, infection, scarring of the area and nerve damage.
• Unsterile equipment and needles can spread infectious diseases; it is extremely
  important to be sure that all equipment is clean and sanitary before use.
• You may not be allowed to donate blood either temporarily or permanently. 

The Body Art Practitioner should

• Properly and thoroughly cleanse the area before the procedure
• Use sterilized equipment
• Use sterile techniques
• Provide information on the aftercare of the area receiving body art

HEALTH HISTORY AND INFORMED CONSENT
The following conditions may increase health risks associated with receiving body art:
a. diabetes;
b. hemophilia (bleeding);
c. skin diseases, lesions, or skin sensitivities to soaps, disinfectants etc.;
d. history of allergies or adverse reactions to pigments, dyes, or other sensitivities;
e. history of epilepsy, seizures, fainting, or narcolepsy;
f. use of medications such as anticoagulants, (such as Coumadin) which thin the blood
and/or interfere with blood clotting; and
g. hepatitis or HIV infection

INSTRUCTIONS FOR THE AFTERCARE OF PIERCINGS

• Before cleaning, wash hands thoroughly with soap and warm water.
• Treat your new piercing as an open wound.  Keep it clean. Body piercings need to be
  cleaned once or twice daily, every day, for the entire initial healing time. Do not
  touch healing piercings with dirty hands.
• Rinse or soak the pierced area with warm water to remove any stubborn crust using
  a cotton swab and warm water.
• Apply a small handful of mild antibacterial soap to the area with your clean hands.
• Cleanse the area and the jewelry, and gently rotate the jewelry back and forth a few
  times to work the soap to the inside.
• Allow the solution to remain there for a minute. Bathe normally; don't purposely
  work anything other than the cleanser onto the inside of the piercing.
• Rinse the area thoroughly under running water, while rotating the jewelry back and
  forth to completely remove the cleanser from the inside and outside of the piercing.
• Gently pat dry with disposable paper products such as gauze or tissues, as cloth
  towels can harbor bacteria. 

Consult a health care provider for:
1. unexpected redness, tenderness or swelling at the site of the piercing
2. rash
3. unexpected drainage at or from the site of the piercing

4. fever within 24 hours of the piercing

PROCEDURE FOR FILING A COMPLAINT
If there is any injury, infection, complication or disease as a result of a body art procedure
notify this establishment, and the Burlington Board of Health, 61 Center St., Burlington, MA
at 781-270-1955.

CLIENT SIGNATURE
I have received the above information.  I do not have a condition that prevents me from
receiving body art. I consent to the performance of the body art procedure and I have been
given verbal and written aftercare instructions as required by these regulations.

For Jewelry Change Appointments, Rowan shall not be held liable for any damage that may occur to non-Rowan jewelry. By signing this waiver, you acknowledge that Rowan, along with its agents, will not be responsible for any such damage from all claims and losses arising from such incidents.

For South Carolina Customers Only:  If indicated above that the Customer has or has previously had any of the listed health conditions, you are required to provide Rowan, Inc. with documentation from a physician or other legally authorized healthcare provider that the piercing procedure is not contraindicated.  Such documentation must be furnished at the time that piercing services are to be provided.
Obtaining any body piercing may disqualify you as a blood donor according to the standards of the American Association of Blood Banks.

For Minnesota Customers Only:  Rowan may decline to perform the piercing procedure if the Customer has any of the above identified health conditions. 

Notice Regarding Permanence of Body Piercing.  Body piercing procedures are permanent in nature and may leave visible scarring.  
Aftercare.  I understand and acknowledge the importance of proper aftercare in reducing the risk of infection or other medical complications following any piercing procedure. I understand that, despite Rowan’s best efforts and the Customer’s proper after care, the potential for infection or other medical complications still exists.  I also acknowledge that certain known or unknown medical conditions, medications, and medical treatments can impede the healing process, and therefore Rowan cannot guarantee healing times.  I have read, understand, and agree to follow each step of the instructions regarding Piercing Aftercare which has also been explained to me verbally. Further, I understand that since Rowan will not have the opportunity to monitor my at home after care, it is solely my responsibility to follow the Piercing Aftercare instructions provided at the time of the ear piercing. 

For Customers in Cambridge, Massachusetts: For any questions or concerns regarding safety, sanitization, or sterilization procedures, contact the Cambridge Public Health Department at (617)665-3826.
For Customers in Wayne County, Michigan:  For any questions, concerns or complaints regarding safety, sanitization, sterilization, or other procedures, contact the Wayne County Department of Public Health at (737)727-7000.
For Customers in Texas:  Report any diagnosed infection, allergic reaction, or adverse reaction resulting from the piercing to the artist and to the Texas Department of State Health Services at 1-888-839-6676.

Photographic Release.  I grant permission and consent to Rowan for the use of a close up photograph of the piercing completed for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, advertising, marketing, and web content.  Furthermore, I hereby grant Rowan and its representatives the right to take photographs and/or videos of my ear piercing procedure (“Images”) and authorize Rowan to use such Images for internal training purposes. [If I do not wish my Images to be used for Rowan’s internal training purposes, I understand that I can opt-out by notifying Rowan’s staff at any time before the ear piercing procedure.]

I understand that there shall be no payment, royalties or other compensation, or revocation for this release.

Release of Liability/Waiver of Claims.  I hereby agree to accept and assume all risks of illness, personal injury, psychological injury, pain, suffering, disability, death, property damage, and/or financial loss arising from the above described piercing procedure.  I hereby expressly waive and release any and all claims, now known or hereafter known, against Rowan, its officers, managers, agents, employees, directors, representatives, independent contractors, retail partners, affiliates, successors, and assigns (collectively “Releasees”) on account of personal or psychological injury, illness, pain, suffering, disability, death, property damage, or financial loss arising out of or attributable to the ear piercing, whether arising out of the ordinary negligence of Rowan or any Releasees, my failure to carefully adhere to all aftercare instructions, or otherwise.  I covenant not to make or bring any such claim against Rowan or any other Releasee, and forever release and discharge Rowan and all other Releasees from liability under such claims.  This waiver and release does not extend to claims for gross negligence, willful misconduct, or any other liabilities that state law does not permit to be released by agreement. 

Other. This Ear Piercing and Aftercare Waiver, Release and Consent Form (the “Agreement”) constitutes the sole and entire agreement of Rowan, Inc. and the signatory below with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations and warranties, both written and oral, with respect to such subject matter. No personal information provided within this waiver will be shared with any third party, unless required by law. I expressly agree that this Agreement is intended to be as broad and inclusive as permitted by the laws of the State of New York, and that this Agreement shall be governed by and interpreted in accordance with the laws of the state of New York, unless applicable law requires otherwise.  I agree that in the event that any clause or provision of this Agreement shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Agreement which shall continue to be enforceable.
I, the undersigned, acknowledge and agree that I have read this Ear Piercing and Aftercare Waiver, Release and Consent Agreement in its entirety, fully understand and agree to its contents.  I confirm that the information herein regarding health conditions which may increase any health risks associated with this piercing have been explained to me verbally; that the Customer does not have any health conditions that would prevent the Customer from receiving the piercing procedure described herein; and hereby grant Rowan, Inc. consent to perform the ear piercing described above on the Customer.  I understand that Rowan, Inc. will not perform the requested piercing services unless this form is completed in its entirety and signed by me.  I further represent and warrant that all information set forth above is true and correct, and that the Customer willingly submits to the piercing procedure described herein.

For customers in Denver, Colorado: Outside of the normal limits of healing, any concerns that your body art has resulted in complications, infection or disease should be reported to:         
Denver Department of Environmental Health
Public Health Inspection- Body Art
200 W 14th Ave. Dept 200
Denver, CO 80204
720-913-1311
You may also report to your artist any concerns about complications, infections or disease.  The rules and regulations governing body art establishments and body artists require that the body artist report those conditions to the Department within 24 hours of discovery.

Note: Rowan reserves the right to refuse to perform body art on any minor at any time and for any reason, regardless of the provision of parental consent.