Attachment Issues Jewelry — Digital Client Waiver & Consent

ATTACHMENT ISSUES JEWELRY

Jewelry that won’t let go.

319 Center Street, Douglas, WY 82633  •  (307) 241-9952  •  bookings@attachmentissuesjewelry.com

PERMANENT JEWELRY — CLIENT WAIVER, HEALTH SCREEN & CONSENT FORM

Please read this form carefully and complete all sections. This form must be signed before your appointment begins. It is the digital twin of the paper waiver — same wording, same health screen, same release. If you prefer paper, a printed copy is available at the appointment.

1. Client Information

2. Health Screening

Please answer honestly. A “yes” does not automatically disqualify you, but the service may be postponed or declined for your safety.

1. Do you have a pacemaker or any other implanted electronic or medical device? *

Please stop — do not proceed with welding. A pacemaker or implanted device means this service cannot go ahead as booked. Your answers will be saved for staff review, and the studio will contact you. If you answered yes by mistake, change it back to No.

2. Do you have an allergy or sensitivity to any metal (including nickel, gold, silver, platinum, or stainless steel)? *

3. Are you pregnant? *

4. Do you have photosensitivity or photosensitive epilepsy, or take any medication that increases sensitivity to light (such as certain antibiotics or retinoids)? *

5. At the area where the jewelry will be placed, do you have any rash, eczema, psoriasis, sunburn, irritation, open cuts, sores, or broken skin? *

6. Have you had surgery, an injury, or a medical procedure at that area recently? *

7. Do you have any other medical condition or concern we should know about before welding? *

3. Acknowledgments — please tick each line

4. Assumption of Risk, Release & Indemnification

I voluntarily request permanent jewelry services from Attachment Issues Jewelry LLC (“the Business”). I understand and accept the risks described in this form, including minor burns, skin or allergic reactions, and damage to or loss of the jewelry. To the fullest extent permitted by Wyoming law, I release and hold harmless the Business, its owner, and its staff from claims, demands, and causes of action arising out of the services described here, except those caused by the Business’s gross negligence or willful misconduct. I agree to indemnify the Business against claims brought by anyone else arising from my receipt of these services or from information I provided on this form being inaccurate.

I confirm the health information above is complete and accurate, and I consent to the service described. I understand the Business may decline or stop a service at any time if it appears unsafe.

5. Clients Under 18

Clients under 18 must have a parent or legal guardian present, and the guardian must co-sign below. The Business may decline to serve minors at its discretion.

6. Photo Release (optional — service is not affected by your choice)

7. Signatures

Signing confirms the health information above is complete and accurate.
Aftercare: Your jewelry is low-maintenance. Clean gently with warm water and mild soap as needed, and pat dry. Avoid harsh chemicals where possible. If your jewelry catches or breaks, keep the chain and contact us about a re-weld — do not attempt to weld or solder it yourself. For skin irritation that does not resolve, remove the jewelry and consult a medical professional.

This form is a template, not attorney-reviewed. It should be reviewed by the Business’s insurer or attorney before first use. A signed copy should be kept on file for each client. Paper copies of the same form are available at the studio.