Piercing (Minor) Release Form

Basic Info:

Today's Date:

Mon Jun 22 2026 07:32:49

Artist:*

How did you hear about us?:*

Studio: Cherry Bomb Studio Address: 231 Eldridge Street, New York, NY 10002 Telephone: (929) 434-8004 Name of Legal Operator: Mason Lykes

Please read & answer:

Booking & Pricing*

I understand and agree to the booking and pricing information listed below on behalf of myself and the minor receiving the piercing service.

Booking Fee: If a booking fee was paid when scheduling the appointment, it will be applied toward the final bill.

Jewelry: Jewelry is purchased separately and ranges from $30 to $500 depending on the piercing and the type of metal selected.

Pricing: I confirm that the piercer has provided the final price for the service (barring any changes) and I agree to pay the full amount due at the completion of the procedure.

Release*

By signing this Release, I have been given the full opportunity to ask all questions that I might have about obtaining a piercing, and all my questions have been answered to my complete and total satisfaction. I acknowledge I have been advised of the matters set forth below, and I agree as follows:

It is important to be aware of the potential health risks associated with body piercing, which may include allergic reactions, skin infections, hepatitis, prolonged bleeding, swelling, scarring, and general discomfort.

Existing medical conditions—such as allergies, heart disease, diabetes, skin disorders, or conditions that affect the immune system—may increase the risk of complications from body piercing. Before providing consent for body piercing, you are encouraged to speak with a physician regarding potential health risks for your child.

New York State Public Health Law Article 4-A, Section 460-a, prohibits the owner, operator, or employee of a body piercing studio from performing a body piercing on a person under eighteen (18) years of age unless a parent or legal guardian provides written consent.

To provide consent, the parent or legal guardian must complete and sign this form in the presence of the owner of the body piercing studio or the studio’s body piercing specialist. The original written consent will be retained by the body piercing studio and will expire twelve (12) months from the date it is signed.

I give consent to the owner of this body piercing studio and/or the body piercing specialist named above, to body pierce my child who is under the age of eighteen years of age.

Limitations*

This consent is limited to the following type(s) and location(s) of body piercing(s):

Health History*

I confirm that the minor receiving the piercing is not pregnant or nursing. If the minor has any condition that may affect the healing of this piercing, I will inform the Piercer prior to the procedure.

I confirm that the minor does not suffer from medical or skin conditions including, but not limited to, keloid or hypertrophic scarring, psoriasis at the piercing site, or any open wounds or lesions at the intended piercing site.

I confirm that I have advised the Piercer of any known allergies the minor may have, including allergies to metals, latex gloves, soaps, or medications.

I acknowledge that the Piercer cannot determine whether the minor may have an allergic reaction to the piercing jewelry or any materials or processes involved in the piercing procedure, and I understand that such a reaction is possible.

I affirm that the minor does not have diabetes, epilepsy, hemophilia, a heart condition, and is not taking blood-thinning medication.

I confirm that the minor does not have any other medical or skin condition that may interfere with the piercing procedure or the healing of the piercing.

I confirm that the minor has not received an organ or bone marrow transplant; if the minor has, I confirm that the minor has followed the prescribed preventive regimen of antibiotics required by their physician before undergoing an invasive procedure such as piercing.

Informed Consent*

I confirm that I am the parent or legal guardian of the minor receiving the piercing service and that I am authorized to provide consent on the minor’s behalf.

I confirm that the minor is not under the influence of drugs or alcohol, and that I am not under the influence of drugs or alcohol at the time of providing this consent.

To the best of my knowledge, the minor does not have any physical, mental, or medical impairment or disability that would affect their well-being as a direct or indirect result of receiving this piercing at this time.

Permanence*

I acknowledge that obtaining this piercing for the minor is a voluntary decision made with my consent as the parent or legal guardian. I understand that this piercing will change the minor’s appearance and that no representation has been made regarding the ability to restore the skin involved to its pre-piercing condition.

I further acknowledge that the piercing may permanently change the minor’s appearance and that even if the jewelry is removed in the future, the skin may not return to its original condition, and scarring, marks, or indentations may remain.

Risks*

I acknowledge that I have been informed of the risks associated with obtaining a piercing for the minor. I understand that known and unknown risks may lead to injury, including but not limited to infection, scarring, keloid formation, and allergic reactions.

Having been informed of the potential risks associated with piercing, I give permission for the minor to receive the piercing and I freely accept and assume all risks that may arise from the procedure.

Aftercare*

I affirm that I have received instructions on how to care for the minor’s piercing while it is healing. I understand these instructions and agree to ensure they are followed during the healing process.

I acknowledge that it is possible for the piercing to become infected, particularly if the aftercare instructions are not followed.

I confirm that I have received the aftercare instructions and agree to ensure they are followed while the minor’s piercing is healing.

Sterilization*

I understand that the minor will be pierced using appropriate sterile instruments and single-use needles, and that sterilization procedures will be used in accordance with standard professional practices.

Minor Name*

Please provide the full name of the minor being pierced.

Minor Birthdate*

Please provide the full birthday (month, day, year) of the minor being pierced.

Indemnification*

I agree to indemnify and defend Ro Bataille, LLC, Iron Cherry, LLC, Cherry Bomb Studio, my service provider, as well as any representatives, employees, contractors, and agents against all claims, causes of action, damages, judgments, costs, or expenses, including attorney fees and other litigation costs, which me in any way arise for my use of or presence upon the facilities of Cherry Bomb Studio located at 231 Eldridge Street.

Unenforceability*

I understand Release of Liability or unenforceability of any provision of this Release of Liability shall not affect any other condition in this Release of Liability or any other applications of such provision, and such unenforceable provision shall be deemed not to be part of this Release of Liability.

Mediation*

I agree that the parties will attempt to resolve any dispute arising from or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to use mediation.

Payments*

I have read and agree with the pricing and policies.

Payment will be made to the Business via cash or any other payment method determined by the Business.

I understand that my final price may differ from what is reflected in this appointment booking due to either error while booking or additional, less, or other services provided.

After completing my service, I agree to pay the remainder of the total final price calculated and requested. If I have questions about pricing, I will ask for that information before my appointment begins.

Unless previous arrangements are made, if I refuse to pay the requested amount at the time of service, my card on file may be charged that amount, and Ro Bataille, LLC will provide me with an itemized receipt of the charges.

No Refunds*

The Customer will be assumed to have accepted the Goods unconditionally. The deposit and final charge are non-refundable.

No refunds will be provided for the work completed or services performed under this Contract.

Authority*

Each party has the authority to enter this Contract and perform all its obligations under it.

Signatures*

This Contract may be signed electronically or in hard copy. Electronic signatures count as original for all purposes.

Changes*

The Client and the Business must agree to any changes to this Contract in writing.

Acknowledgement*

I have read this document and understand its contents. I acknowledge that the information I gave in this form is accurate and complete. I understand that I voluntarily surrender certain rights by signing this Release of Liability. By signing below, I confirm that I understand and agree to all terms and statements in this form.

I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.

I have read and understand this agreement. The nature and purpose of the treatment have been explained to me. All my questions have been answered to my satisfaction, and I consent to the terms of this agreement.

By signing your name as a signature below, you agree to the terms and provisions of this agreement.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Personal Info

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:*

Address:*

Date of birth:*

Phone #:*

Email:*

Signature:*

Minor consent attestation

I, owner or body piercing specialist of Cherry Bomb Studio, attest that the above named parent or legal guardian signed this form in my presence.

Signature:*

Photo ID(s)*

Please take a picture of your government issued photo ID