Parental Consent Form

             Parents, please fully read all information provided on the previous page before making a decision for your child.

 

Lark Vegas Parental Consent

 

 

Albany County Health Department Law requires notarized consent by

 a custodial parent or legal guardian to a body piercing on a minor.

 

                A body piercing is authorized only upon the written, notarized consent of the custodial parent or legal guardian, who must file the same in person at the body piercing shop and complete a written record at the shop. The parent must be present with the minor and proper identification for both the parent and minor are required at that time. If you are the legal guardian we require a copy of those court documents, for our records.

 

Please initial after reading and accepting the following information:

 

           Due to the natural growth and hormonal changes taking place in the adolescent body I understand that minors have a much greater risk of complications while healing. Including but not limited to; rejection, migration, granulomas and hematomas which are common and possible. These complications could cause scarring and tissue damage. ___________

 

           I understand there is always some risk associated with any piercing. This includes vascular damage, as the technician cannot fully see through the skin. I understand the technician will take precautions to avoid any obvious veins, capillaries and arteries. _________

 

           I have received or will receive complete written instructions concerning the aftercare procedures required to be followed in order to help properly heal a body piercing. I understand my child is only in the care of the piercing technician for a few moments and that a body piercing can take several months of diligent care and cleaning to heal properly. I understand it is my responsibility as the parent or legal guardian to insure that the proper care is taken for the next several months. ____________

 

*I have FULLY researched and considered the decision I am making for my child and accept the responsibility and risks associated with my decision.   _____________

 

  I, ____________________________________, residing at ___________________________,

city of __________________, state of ______________, do certify that I am the custodial parent or legal guardian of _______________________________, D.O.B. _______________, a person under the age of eighteen years and at least sixteen years old. 

 

I hereby consent to the administration upon said minor of the following body piercing procedure___________________.  To be performed at Lark Vegas Piercing Co. LLC. Located at, 273 Lark St, Albany, NY, 12210,  by, Rebecca or Calley.

                                                                                                                                                                                            

Signature of parent or legal guardian  X_____________________________________

 

 

State of New York}

 

County of Albany} SS.:

 

 On this _________ day of ____________, before me, the subscriber, personally appeared

____________________________________________, to me personally know and known to me to be the same person described in and who executed the foregoing consent and she/he did acknowledge to me that he/she executed the same.

 

                                                                                                                                                                                                                                                                                                                                                                Notary Public  X_____________________________________

Select the following text and choose print selection