I acknowledge by signing this agreement that I have been given the full opportunity to ask all questions which I might have about the obtaining of a body piercing or alternate procedure and that all my questions have been answered to my full satisfaction. I especially acknowledge that I have been advised of the facts and matters set forth below and I agree as follows:

• 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 my piercer of any condition such as diabetes that might hamper the healing of the piercing.
• 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.
• I do not suffer from medical or skin conditions such as, but not limited to, keloid or hypertrophic scarring, psoriasis at the sight of the piercing or any open wounds, infections, rashes, or lesions at the sight of the piercing.
• I have advised the piercer of any allergies 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.
• I have truthfully represented to the piercer that I am over the age of 18 years old. I am not under the influence of drugs or alcohol. To my knowledge, I do not have 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.
• I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to restore the skin involved in this piercing to its pre-piercing condition.
• I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and agree to follow all the necessary instructions while the piercing is healing.
• I understand that a micro-dermal (surface anchor) consists of a pierced point of entry but not a point of exit. Specially designed jewellery is inserted into the pierced area and sits below the skin where it becomes anchored.
• I understand I will be pierced using appropriate instruments and sterilization.
• I understand that Beyond Body Modification reserves all right to use any photos taken of my piercings or modification.

Therefore, I request the piercer to pierce me. I understand this type of piercing takes time to heal. I hereby release and forever discharge and hold harmless Beyond Body Modification, the piercer, all affiliates, owners, managers and employees from all claims, damages, or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing, to the fullest extent allowed by law.