PIERCING AND AFTERCARE
WAIVER OF LIABILITY, RELEASE OF CLAIMS AND ASSUMPTION OF RISK
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.
This Piercing and Aftercare WAIVER OF LIABILITY, RELEASE OF CLAIMS AND ASSUMPTION OF RISK (the “Waiver”) is executed between Rowan, Inc. (“Rowan”) and the individual signing below (the “Adult Signer”). If the individual upon whom the piercing is being performed (the “Participant”) is over the age of 18, then the Adult Signer represents that he or she is the Participant. If the Participant is under the age of 18, the Adult Signer represents that he or she is the parent or legal guardian of the Participant.
In consideration of the Participant receiving an ear or nose piercing service, post change service, jewelry change, aftercare products and/or general aftercare feedback (collectively, “the Services”), the Adult Signer hereby agrees to the following terms and conditions contained in this Waiver.
1. PARENT OR GUARDIAN RELATIONSHIP (for Minor Participants only). I represent that I am the parent or legal guardian of the Participant. In the event the foregoing is not accurate, I agree to indemnify, defend and hold harmless Rowan and the Rowan Releasees (as defined below) from any and all liability, loss, cost, claim or damage whatsoever which may be imposed upon or threatened against said parties relating to or arising from my misrepresentation. Furthermore, I acknowledge and agree that Rowan in its sole discretion may refuse to perform body art on any minor at any time and for any reason, regardless of the provision of parental consent.
For Minor Participants in Tennessee: “I, the undersigned, certify that I am the parent, legal guardian, or legal custodian of the named minor and further give consent to the body piercing procedure(s) as explained. I acknowledge that I am fully aware that to falsify my legal standing as to being the minor’s parent, legal guardian or legal custodian constitutes a Class C misdemeanor. A Class C misdemeanor means imprisonment for not greater than thirty (30) days or a fine not to exceed fifty dollars ($50.00) or both. (T.C.A. 40-35-111).”
2. ASSUMPTION OF RISK; NO GUARANTEES. I acknowledge and agree that there are inherent risks and injuries that may occur in connection with receiving an ear and/or nose piercing. While Rowan has developed its procedures and training with safety as a prime concern, is committed to minimizing negative piercing outcomes for its customers, and provides aftercare guidance and instruction to its customers, it is impossible to eliminate all risk and possibility of injury. I hereby agree to accept and assume all risks of illness, personal injury, physical or psychological injury, pain, suffering, disability, death, property damage, and/or financial loss arising from the Services. I further understand that there is no guarantee of satisfactory aesthetic results.
3. TYPES OF RISKS; HEALTH RISK ADVISORY. I understand that there are inherent health risks associated with the Services 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 and individuals with existing or a history of certain medical conditions. If you experience extreme swelling or embedded jewelry, yellow-green or foul-smelling discharge, a fever (temperature of 100.4 °F or higher), an area warm to the touch, extreme pain, or any symptoms that don't improve over time, please contact your health care provider to seek prompt medical care.
Heightened Risk Categories. 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 acknowledge and agree it is my responsibility to consult with a physician prior to the Services if the Participant falls into any of the above heightened risk categories. NOTWITHSTANDING THESE RISKS, I ACKNOWLEDGE THAT I AM VOLUNTARILY CHOOSING TO PROCEED WITH THE PIERCING PROCEDURE AND SERVICES WITH KNOWLEDGE OF THE RISKS INVOLVED.
COUNTY AND STATE SPECIFIC REQUIREMENTS.
For Participants in Alameda County, California Customers: 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 Participants 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.
For Participants in Fulton County, Georgia and Minnesota Customers: I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing without duress or coercion.
For Participants in Illinois, Louisiana, Cambridge County, Massachusetts, Minnesota, and South Carolina: To ensure that your body piercing procedure heals properly, please 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 Participants in Burlington, Massachusetts:
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
- 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.
- Before cleaning, wash hands thoroughly with soap and warm water.
- 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 Participants 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 Participants 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 Participants in Minnesota: 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 Participants in Clark County, Nevada per the Southern Nevada Health District:
Please note the Risk Notification Section of this waiver:
a. Body art can cause swelling, bruising, discomfort, bleeding, and pain.
b. Body art can cause allergic reactions.
c. Body art can cause irreversible changes to the human body.
d. Body art has a risk of infection.
e. Any effective removal of the body artwork may leave permanent scarring and disfigurement.
Please note the Informed Consent Section of this waiver:
a. Patrons are voluntarily obtaining services of their own free will and volition,
b. Patrons have had the opportunity to read and understand the document,
c. Patrons have the ability to ask questions about the procedure,
d. Patrons have received and understand written and verbal aftercare.
Please note that Rowan will not perform a piercing on a customer
If customer is under the influence of drugs or alcohol
If customer has ingested anticoagulants (such as heparin or warfarin), antiplatelet drugs, or nonsteroidal anti-inflammatory drugs (NSAIDS) (such as aspirin, ibuprofen, etc.) in the last 24 hours
If a customer has ingested any medication that can inhibit the ability to heal a skin wound, the piercing procedure is under the discretion of the nurse.
For Participants in South Carolina: 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 Participants 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.
RELEASE OF CLAIMS; WAIVER OF LIABILITY. To the fullest extent permitted by applicable law, I hereby expressly waive and release Rowan, its officers, owners, agents, employees, directors, medical advisory board members, representatives, independent contractors, retail partners, landlords, affiliates, successors, and assigns (collectively “Rowan Releasees”) from and against all liabilities, losses, damages, claims, causes of action, proceedings, costs, fees, expenses, medical bills, property damage, theft, economic losses and demands whatsoever or any kind (including attorney’s fees and court costs) (collectively, “Losses”), known or unknown, currently existing or may arise in the future, relating to, resulting from, or arising out of (in whole or in part) Participant’s participation in the Services. The foregoing waiver and release includes, but is not limited to, Losses occurring in or about the premises where the Services took place, Losses from physical or psychological injury and Losses due to negligence (and where permitted by applicable law, gross negligence or willful misconduct) of the Rowan Releasees. Further, I (and on behalf my heirs, executors and representatives) hereby AGREE NOT TO SUE or otherwise make or bring any such claim or proceeding for Losses against the Rowan Releasees, and forever release and discharge the Rowan Releasees from and against any and all such Losses. To the extent Losses are not barred by this Waiver, the Adult Signer acknowledges that any damages awarded shall be reduced in proportion of the percentage of fault, if any, attributable to the Participant and, if applicable, the Participant’s parent or legal guardian.
PHOTOGRAPHIC RELEASE; OPT-OUT. 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, illustration, advertising, marketing and internal training. If I do not wish for the Participant’s 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 Services. I understand that there shall be no payment, royalties or other compensation, or revocation for this release.
SOLE AGREEMENT; SEVERABILITY; MISC. This Waiver constitutes the sole and entire agreement between Rowan and the Adult Signer 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 Waiver shall be held to be invalid or unenforceable by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Waiver which shall continue to be enforceable. I understand and agree that my electronic signature is legally binding equivalent to my handwritten signature.
CONSENT TO SERVICES. I acknowledge and agree that I have read this Waiver in its entirety and 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.
By accepting the Services, I am affirmatively representing to Rowan that (x) the Participant has no existing medical condition or history of medical conditions that make the Services inadvisable and/or (y) I have consulted with and been cleared by a physician to accept the Services despite my current or prior medical conditions. Rowan is entitled to rely on these representations and has no duty to independently verify the same.
I hereby grant Rowan consent to perform the Services on the Participant. I understand that Rowan will not perform the requested 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 Participant willingly submits to the Services described herein.